DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,GURGAON-122001.
Consumer Complaint No: 956 of 2009 Date of Institution: 16.11.2009 Date of Decision: 10.11.2015.
Sameer Srivastava s/o Sh.Ram Kumar Srivastava, R/o C-365-B, Sushant Lok-1, Gurgaon, Haryana.
……Complainant.
Versus
- Star Health and Allied Insurance Co. Ltd No.1, New Tank Road, Valluvarkottam High Road, Nungambakkam, Chennai-34 through its Managing Director.
- Star Health and Allied Insurance Co. Ltd, SCO-18, Saraswathi Vihar Shopping Complex, IInd Floor, Gurgaon-122 001 through its Branch Manager.
..Opposite parties
Complaint under Sections 12 & 14 of Consumer Protection Act,1986
BEFORE: SH.SUBHASH GOYAL, PRESIDENT.
SMT JYOTI SIWACH, MEMBER
SH.SURENDER SINGH BALYAN, MEMBER.
Present: Sh. Virender Yadav, Adv for the complainant.
Sh. K.K.Aggarwal, Adv for the opposite parties.
ORDER SUBHASH GOYAL, PRESIDENT.
The case of the complainant, in brief, is that he obtained Medi Classic Individual Policy from the OP-Insurance Company which was valid w.e.f.03.02.2009 to 02.02.2010 and during the subsistence of the insurance policy on 24.04.2009 the complainant developed left leg problem along with fever and he was taken to Paras Hospital, Gurgaon and was admitted in the said hospital. The cashless facility was declined by the opposite parties on frivolous grounds. The complainant remained hospitalized in the said hospital till 29.04.2009 and paid a sum of Rs.71,631/- towards treatment in the said hospital. The complainant lodged the claim with the opposite parties but the same was repudiated on the ground of non disclosure of pre-existing disease which tantamounts to deficiency in service on the part of the opposite parties. The complainant prayed that the opposite parties be directed to reimburse the claim of Rs.72,080/- with interest @ 10 % p.a. The complaint is supported with documents placed on file.
2 The opposite party in their joint written reply have alleged that pre-existing disease are covered only after 48 months of continuous insurance policy with the company. The complainant has suppressed the material fact of suffering from diabetes at the time of obtaining the insurance policy and thus, the repudiation of the claim of the complainant for reimbursement of the mediclaim was justified and there was no deficiency of service on the part of the opposite parties.
3 We have heard the parties and perused the record available on file carefully.
4 Therefore, from the facts and circumstances of the case, evidence on the file and the arguments advanced by the parties besides written arguments filed by the opposite parties, it emerges that the complainant has filed the present complaint against the OPs alleging deficiency in service on their part on the ground that he obtained Medi-Classic Individual Policy bearing No.P/161117/01/2009/001093 which was valid w.e.f.03.02.2009 to 02.02.2010 and during the subsistence of insurance policy i.e. on 24.04.2009 the complainant developed problem in left leg along with fever and he was taken Paras Hospital, Gurgaon where he remained admitted from 24.04.2009 to 29.04.2009 and incurred a sum of Rs.71,631/-. However, the request for cashless facility was declined by the opposite parties. The complainant submitted a claim for Rs.72,080/- for reimbursement which was repudiated by the opposite parties wrongly and illegally on the ground of non-disclosure of pre-existing disease which tantamounts to deficiency in service on the part of the opposite parties. In support of his contention learned counsel for the complainant has placed reliance on IFFCO TOKIO General Insurance Co. Ltd Vs Permanent Lok Adalat (Public Utility Services), Gurgaon 2012(1) RCR (Civil) 901, New India Assurance Co. Ltd & Anr Vs Murari Lal Bhusri III(2011) CPJ 198 (NC) and New India Assurance Co. Ltd Vs Rakesh Kumar in RP No.2157 of 2014 decided on 01.07.2014 by Hon’ble National Consumer Disputes Redressal Commission, New Delhi.
5 However, as per the contention of the opposite parties, pre-existing disease was not covered as per the terms and conditions of the policy rather pre-existing disease was liable to be reimbursed after 48 months in terms of the policy and the complainant has suppressed the factum of suffering from diabetes at the time of availing the policy and thus, the claim of the complainant was rightly repudiated by the opposite parties and there was no deficiency in service on the part of the opposite parties. In support of his contention learned counsel for the opposite party has placed reliance on Manjit Kaur Vs New India Assurance Co. Ltd III(2003) CPJ 608
6 Therefore, after through the facts and circumstances of the case and the evidence placed on file it is evident that the claim has been repudiated only with the ground that the complainant has suppressed the material fact of suffering of pre-existing disease i.e. diabetes as mentioned in the Discharge Summary. However, after going through the Discharge Summary it emerges that doctor has mentioned that there was swelling on the left leg 2/3 months back. However, the policy was obtained and effective from 03.02.2009 to 02.02.2010 and the complainant got himself admitted on 24.04.2009 and as such it cannot be inferred that mentioning of 2/3 months in the Discharge Summary would tantamount to suppression of fact. There is absolutely no document on the file on behalf of the opposite parties that complainant was suffering from Cellulites which has been made basis by the opposite parties to repudiate the claim. There is nothing on the file that the trauma from which the complainant was suffering was the result of alleged diabetes. Therefore, in absence of the same it cannot be assumed that the complainant had suppressed the factum of pre-existing disease and as such the repudiation of claim was unjustified.
7 Therefore, keeping in view the facts and circumstances of the case we hold that there was deficiency in service on the part of the opposite parties. We direct the opposite parties to reimburse the claim of Rs.71,631/- with interest @ 9 % p.a. from the date of filing of the present complaint till realization. The complainant is also entitled to compensation of Rs.10,000/- for harassment and mental agony and Rs.3100/- as cost of litigation. The opposite parties shall make the compliance of the order within 30 days from the date of receipt of the copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the records after due compliance.
Announced (Subhash Goyal)
10.11.2015 President,
District Consumer Disputes
Redressal Forum, Gurgaon
(Jyoti Siwach) (Surender Singh Balyan)
Member Member
