PRESENT:-
Complainant by Adv. Karmarkar
Opponent No. 1 to 2 by Adv. Ashita Parmar
ORDER
(Per- Mr. S. S. Vyavahare, Hon’ble President.)
1) The complainant has filed this complainant under Section 12 of the Consumer Protection Act, against the opponents for getting compensation alleging deficiency of service on their part.
2) Facts giving rise to the present complaint in short are as under.
3) Opponent No.1 deals in insurance business whereas opponent No.2 is a branch office of opponent No.1. The opponent No.1 & 2 deals in the business of insurance under the name & style Star Health & Insurance Co. Ltd. The offices of the opponent No.1 & 2 are situated on the addresses mentioned in the complaint.
4) Complainant resides at Thane-West. In the year 2011 the complainant has obtained mediclaim policy from the opponents and the period of the same policy was from 18/01/2011 to 17/01/2012. The coverage of the said policy was for Rs.2,00,000/- The complainant had paid Rs.7,114/- towards the premium of the said policy. Complainant, his wife and his two daughters were the beneficiaries under said mediclaim policy. The said mediclaim policy was renewed from 2011 till 2013.
5) In the year 2013 wife of the complainant has severe chest pain and therefore complainant took her to Dr. Dayandna Kumble who has diagnosed the sickness of complaint’s wife as EPRFA and advised the complainant to perform the surgery of his wife. The complainant enquired for required surgery with private doctor and Rs.1,50,000/- was the estimated cost of the surgery. Since, the financial condition of the complainant was not sound and therefore he has performed the said surgery at KEM Hospital, Mumbai and spent Rs.75,000/-. Since the complainant has obtained mediclaim policy from the opponents, he has informed to the opponents about the said sickness and surgery and also produced required information. However, the opponents has repudiated the medical claim of the complainant vide letter dated 07/10/2013. The complainant entered into correspondence with opponents. However, opponents did not accept the request of the complainant. Therefore alleging the said act of the opponents as deficiency of service, the complainant has filed present complaint and claimed reimbursement of Rs.65,000/- with 18% interest, plus Rs.1,00,000/- towards compensation for mental agony and cost of the complaint.
6) Opponents have resisted the complainant by filing their written statement. Wherein they have contended that complainant’s complaint is false, frivolous and not based on true facts. According to opponents there is no cause of action to the complaint and therefore opponents deny all adverse allegations of deficiency of service. The opponents have also challenged the jurisdiction of forum to entertain the complaint. While admitting the mediclaim policy obtained by the complainant, the opponents also admit the premium of the said mediclaim policy paid by the complainant and the renewal of said policy from time to time. The opponents do not dispute the mediclaim preferred by the complainant. They also admit the repudiation of said mediclaim by the opponents. However, while justifying the repudiation of mediclaim, the opponents submit that, the wife of the complainant has cardiac problem known as atrioventricular nodal re-entry tachycardia (AVNRT) which was three to four year prior to mediclaim policy. The complainant while taking mediclaim policy for his wife did not disclose said mediclaim problem of his wife to opponents and concealed this material fact. The mediclaim policy taken by the complainant is a contract between him and opponents and as per condition No. 7 of the policy in case of concealment of any sickness from the opponents is a ground for repudiation of the contract. Therefore according to opponents the mediclaim policy of the complainant was rightly rejected. Opponents therefore deny any deficiency of service on their part and pray to reject the complaint.
7) On respective contentions of the parties following points arises for our considerations. Our findings are recorded against the same.
POINTS
- Does the complainant prove that opponents have indulged in deficiency of service by repudiating mediclaim of the complainant? Yes.
- Whether complainant is entitled to get compensation & reimbursement? Yes.
- What order? As per final order
REASONS
Admitted Facts
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9) The policy obtained by the complainant in the year 2011, the converge of said policy of Rs.2/- to the complainant, his wife and two daughters, the premium of the said policy and its payment, renewal of said policy from 2011 to 2013, hospitalization of the complainant at KEM Hospital and the surgery undergone by wife of the complainant is not disputed. The of Rs.65/- by the complainant and its repudiation by the opponents is not disputed.
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- field to not diagnose her ailment as a cardiac problem. We are of the clear opinion that merely because wife of the complainant had symptoms of cardiac problem two to three years back prior to her admission at KEM Hospital that alone is not sufficient to jump to a conclusion that she was suffering from cardiac problems since two to three years prior to her admission at KEM Hospital. We are also of the opinion that, when the opponents are repudiating the claim on the ground of misrepresentation and concealment of material fact it was obligatory on the part of opponent to produce cognate medical papers to show that complainant was well aware about the medical problem of his wife as cardiac problem. The opponents could have done so by producing the earlier medical record of the complainant’s wife which they have totally failed to do. Therefore our conscious does not permit us to swayed away in the submissions advanced by the learned counsel for the opponents. Therefore we do not accept arguments advanced on behalf of the opponents. Since the opponents have repudiated the claim during the period of mediclaim policy, we hold that the said act on the part of opponents amounts to deficiency of service. Therefore we reimburse Rs.65,000- with 10% interest and grant compensation for mental agony and cost of the complaint. With this we decide point No. 1 & 2 in affirmative and pass following order.
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- Compliant is allowed.
- It is hereby declared that opponents have indulged in deficiency of service by repudiating the claim of the complainant.
- The opponents jointly and severally are directed to pay Rs.65,000/- with 10% interest from the date of complaint till its realization and compensation of Rs. 40,000/- towards mental agony and Rs.5,000/- towards cost of the complaint.
- Opponents are directed to file compliance/non-compliance affidavit on or before 16/11/2015.
