BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BHIWANI.
Complaint No.:271 of 2015.
Date of Institution: 21.09.2015.
Date of Decision:-22.11.2017
Master Chirag son of Sh. Rajesh Kumar son of Sh. Ramavtar Gupta, through his father Sh. Rajesh Kumar, resident of Alampuriya Bhawan opposite Agarsain Bhawan, Tehsil Tosham, District Bhiwani.
….Complainant.
Versus
- Star Health and allied Insurance Company Limited, 3rd Floor, Ashok plaza, Delhi Road, Rohtak through its G.M./M.D.
- Branch Office of Star Health and allied Insurance Company Limited, Shop No. 12, 1st Floor City Mall, Bhiwani through its branch Manager.
…...Opposite Parties.
COMPLAINT U/S 12 OF CONSUMER PROECTION ACT
BEFORE: - Mr. Rajesh Jindal, President
Mr. Parmod Kumar, Member
Present:- Shri Telu Ram, Advocate for complainant.
Shri A. Sardana, Advocate for OP no. 1.
OP no. 2 exparte.
ORDER:-
Rajesh Jindal, President:
The case of the complainant in brief, is that the complainant has purchased a family health optima insurance policy bearing no. P/211118/01/2014/001314 on dated 28.3.2014 for a period of one year and he has paid premium for the said policy. The complainant master Chirag fell ill all office sudden and a sum of Rs. 58,000/- had been spent on his treatment and transportation etc. It is alleged that he admitted in the said hospital on 26.6.2014 and immediately intimated the OP about this admission vide intimation no. CLI/2015/211118/0066103. The complainant submitted the bills of Rs. 53,481/- for reimbursement of the said bill but the bill was rejected on 24.9.2014 and thereafter the complainant send the above bill again on 28.10.2014 and the same was also rejected on 25.11.2014. The complainant visited the OP several times but all in vain. The complainant sent a legal notice dated 20.7.2015 but the OP neither paid claimed amount nor responded on the same till today. The complainant further alleged that due to the act and conduct of the respondents, he had to suffer mental agony, humiliation and physical harassment. Hence, it amounts to deficiency in service on the part of respondents and as such he had to file the present complaint for seeking compensation.
2. Upon notice being issued, the opposite party no. 1 contested the case by taking various preliminary objections of maintainability and cause of action etc. in the written statement and on merits submitted that the complainant has submitted the claim records seeking reimbursement of medical expenses for the treatment of pseudo tumor cerebri. It is submitted that the opposite party have processed the claim as per the terms and conditions of the policy based on the documents submitted by the complainant. It is submitted that the maximum quantum of liability under the terms of the policy shall be Rs. 39081/- and the complaint of the complainant may be dismissed with costs in the interest of justice. It is submitted that as per Shakti Neuro Science Centre VEP report dated 5.6.2014 the patient has papilledema with feature of raised intra carnial pressure and at the time of inception of first policy which is from 28.3.2014, the insured had not disclosed the above mentioned medical history of the insured person in the proposal form which amounts to non-disclosure of material fact. Hence, in view of the facts and circumstances mentioned above, there is no deficiency in service on the part of opposite party no. 1 and complaint of the complainant is liable to be dismissed with costs.
3. OP no. 2 has failed to come present. Hence he was proceeded against exparte vide order dated 3.6.2016.
4. The counsel for the complainant has tendered into the evidence documents Annexure C-1 to Annexure C-9 alongwith supporting affidavit.
5. The counsel for the OP no. 1 has tendered into the evidence documents Annexure R-1 to Annexure R-16.
6. We have gone through the record of the case carefully and have heard the learned counsels for the parties.
7. Learned counsel for the complainant reiterated the contents of the complaint. He submitted that the complainant had taken the family health optima insurance policy from the OPs valid for a period of one year from 28.3.2014. The complainant, due to his illness has admitted in the hospital on 26.6.2014 and taken the treatment. The complainant submitted the bill of Rs. 53,481/- to the OP for the reimbursement of the same, but the claim of the complainant was rejected by the OP vide letter dated 24.9.2014. He submitted that the OPs are liable to pay the claim of the complainant under the terms and conditions of the policy.
8. Learned counsel for the OP no. 1 reiterated the contents of he reply. He submitted that the complainant concealed his disease at the time of taking the policy. He submitted that the complainant was suffering from the said disease prior to the taking of the policy. Hence the claim of the complainant was repudiated vide letter dated 24.9.2014 Annexure R-11. He further submitted that without prejudice to the contention of the OP, the maximum quantum of liability under the terms and conditions of the policy shall be Rs. 39081/-.
9. The material facts of the case are not in dispute. The OP has taken the plea that the claim of the complainant was rejected by the OP on the ground that the complainant did not disclose his illness at the time of making proposal for taking the policy in question. The OP has utterly failed to adduce any cogent evidence in support of his contention regarding the prior illness of the complainant. The OP could not give any justified ground for the repudiation of the claim of the complainant. It has been contended by the counsel for the OP that the complainant has submitted the bills to the OP to the extent of Rs. 39,081/- which are detailed in Annexure R-14. No copy of bill has been produced by the complainant on the record. Taking into account each and every aspect of the case, we partly allow the complaint of the complainant against the OPs. The OP are directed to pay Rs. 39081/- alongwith interest at the rate of 8 per cent per annum from the date of filing of the present complaint till the date of payment to the complainant. This order be complied with by the OPs within 60 days from the date of passing of this order. Certified copies of the order be sent to the parties free of costs. File be consigned to the record room, after due compliance.
Announced in open Forum.
Dated: 22.11.2017.
(Rajesh Jindal)
President,
District Consumer Disputes
Redressal Forum, Bhiwani.
(Parmod Kumar)
Member
