Adv.for the complainant-Sri D.Biswal & Associates.
Adv.for the Opp.Party - Sri R.K.Mohakur.
Date of filing of the case-04.08.2016
Date of order - 10.10.2017.
JUDGMENT.
Sri A.K.Purohit, President.
The case of the complainant is that, he had purchased a health surakshya policy from the O.P on dated 29.01.2015 for sum assured of Rs 3,00,000/- and paid Rs 9,973/- towards premium. The said policy is covered the complainant and his family members. Again the complainant renewed the said policy on dt.27.01.2016 and paid the premium amount of Rs 13,423/- under the same terms and conditions of the policy. During subsistence of the said policy the wife of the complainant was admitted in New Apollo Hospital and Diagnostics, Balangir from 13.04.2016 to 21.04.2016 wherein she was undergone abdominal Hysterectomy operation. To this the complainant lodged his claim before the O.P, but the O.Ps have repudiated his claim vide their letter dated 02.06.2016. The complainant alleges that the O.Ps have not explained the risk factor at the time of issuance of the policy and hence repudiation of the claim is not fair. Hence the complaint.
2. The O.P contested the case by filing his written version. According to the O.P genitourinary surgery covers the policy terms and after two years of issuance of policy and since the wife of the complainant undergone surgery treatment before the stipulated period, the policy did not cover the same. The further averment of the O.P is that when the wife of the complainant undergone abdominal hysterectomy within a very short period of issuance of the policy, the complainant has suppressed the pre-existing disease of his wife and hence has violated the terms and conditions of the policy and is not entitled to the claim amount. The O.P denied the allegations of the complainant and claims dismissal of the case.
3. Heard both the parties. Perused the material available on record. It is an admitted fact that the complainant is a policy holder of the O.P and paid premium for the same. It is also an admitted fact that, Health Surakshya policy is covered to the health benefit of the complainant and his family members. The only point for consideration is whether the policy covers abdominal hysterectomy and whether there is any suppression of pre-existing disease by the complainant.
4. Perused the claim repudiation letter issued by the O.P dated 02.06.2016. The ground of repudiation is genitourinary surgery is a pre-existing disease and the same is not covered under the policy before 48, months of its issuance. The O.P has described the genitourinary surgery and abdominal Hysterectomy one and same disease. The O.P has not produced any medical literature or any other evidence to show that both the disease are one and same. In common terms abdominal hysterectomy is a surgical procedure in which he uterus is removed through an incision in the lower abdomen. Genitourinary surgery is a speciality that involves surgical procedure to reproductive and urinary organs. This procedure is mainly meant for treatment of urinary system. Although in both the system there is relation to reproductive organ, but both are not one and same.
5. Abdominal Hysterectomy can be happened at any time due hormonal imbalance or any other reasons. But it cannot be said that it was pre-existing and the same known to the complainant. Further when there is a plea of violation of terms and conditions of the policy, the burden lies on the O.P to prove the same. In the present case, the O.P has not produced the evidence of any medical officer or any other believable evidence.
6. Under the aforesaid facts and discussion it is concluded the repudiation of the claim of the complainant cannot be said to be fair and in accordance with the terms and conditions of the policy. The complainant has produced the bill and money receipt of the hospital amounting to Rs 31,730/- to which he is entitled to. Hence ordered.
ORDER.
The O.P is directed to pay Rs 31,730/- (Rupees Thirty one thousand seven hundred thirty) only to the complainant with 8% interest from the date of repudiation i.e from 02.06.2016 till payment within one month from the date of receipt of this order. The O.P is further directed to pay Rs 500/- (Rupees five hundred) only, towards cost vide order dated 31.08.2017 and to pay Rs 2,000/- (Rupees Two thousand) only towards litigation cost within the aforesaid period.
Accordingly the case is disposed off.
Order pronounced in open forum this the 10th day of October 2017.
(S.Rath) (A.K.Purohit.)
MEMBER PRESIDENT.
