Jharkhand

Bokaro

CC/154/2019

Smt Siyamani Devi - Complainant(s)

Versus

The Branch Manager, National Insurance Co. Ltd. - Opp.Party(s)

Annu Mishra

17 May 2023

ORDER

                District Consumer Disputes Redressal Commission, Bokaro

Date of Filing-18-11-2019

Date of final hearing-17-05-2023

 Date of Order-17-05-2023

Case No. 154/2019

Smt. Siyamani Devi W/o Late Yugal Kishore Singh,

R/o Siyamani Bhavan, Shivpuri Colony, Jodhadih More,

Chas, Bokaro, Jharkhand, 827013

                                      Vrs.

1. The Branch Manager, National Insurance Company Limited Chas Branch Office Natraj Mention, by Pass Road,

Chas 827013

2. Divisional Manager, National Insurance Co. Ltd.

      Natraj Mention P.O. and P.S- Sector-4,

        Bokaro Steel City, Jharkhand, 827004

3.  The Manager, MEDICARE Insurance TPA Services Pvt. Ltd.

6B, BISHOP Lefroy Road, Kolkata, 700020, West Bengal

 

Present:-

                             Shri Jai Prakash Narayan Pandey, President

                 Smt. Baby Kumari, Member

PER- J.P.N Pandey, President

-:Order:-

1. Complainant’s case in brief is that her husband late Yugal Kishore Singh taken a Mediclaim policy vide policy No. 180501/50/17/10000016 later on he became ill and admitted in the hospital on 08.01.2018 for treatment and discharged on 11.01.2018 but again on 11.01.2018 he was admitted in BGH who died on 12.01.2018 itself due cardio respiratory arrest. During treatment complainant paid Rs. 50,896/- thereafter applied for payment of said amount which was repudiated on the ground that deceased was having pre existing disease which was not disclosed at the time of policy. Legal notice was served having no impact hence this case has been filed with prayer to direct the O.P. to pay Rs. 50,896/- to the complainant and also to pay Rs. 20,000/- as compensation and Rs. 20,000/- litigation cost.
2. O.P. Insurance Co. appeared and has filed W.S. mentioning therein that deceased was admitted at BGH Bokaro with complain of HTN, CAD , LV Dysfunction, arterial fibrillation, hemi paresis (past CABG in 2001) on 11.01.2018 performance of CABG in 2001 is evident that the applicant has already been treated for heart disease and current policy on which claim was made was in the second year of the policy in this way claim is excluded under clause 4.1 define for pre-existing disease for which waiting period is prescribed 36 months. Further reply is that the insured has not disclosed that he was under gone for treatment of heart disease at the time of taking the policy, hence there is misrepresentation, mis-description or non disclosure of any material fact, hence claim has been rightly repudiated.
3. Point for consideration is whether complainant is able to get relief as prayed ?
4. To prove its case complainant has filed photo copy of discharge ticket of the deceased, photo copy of policy paper, photo copy of application dt. 16.02.2018 written to the insurance co., photo copy of later dt. 18.03.2018 of the insurance co., photo copy of reply on that very letter, photo copy of claim repudiation letter dt. 20.02.2019, photo copy of letter dt. 08.03.2018 of the insurance co. and photo copy of legal notice dt. 26.09.2019 and its reply by the O.Ps.
5. On perusal of insurance policy it appears that policy was obtained and issued on 22.12.2017 and just after taking the policy within few days deceased was admitted in BGH on 08.01.2018 and discharged on 11.01.2018 who died on 11.01.2018 due to cardio respiratory failure. Discharg slip itself showing that in the year 2005 deceased was treated for cardiac ailment and there was angioplasty in the year 2005 but it appears that said fact was not disclosed before the O.P. at the time of obtaining insurance policy. It is apparent that said disease was pre existing hence in respect to pre existing disease there shall be exclusion of 36 months from the date of inception of first insurance policy. It also appears that in the complaint petition complainant has not disclosed the date on which policy was obtained. Discharge slip shows that there was CLV dis-function, CVR, acute CVA etc. and all these problems are related to heart ailment. However, here in this case except above mentioned papers there is no any paper filed by the complainant to show that she has paid some money towards purchase of the medicines or towards treatment of her husband. Therefore, we are of the view that repudiation of the claim is justifiable and it is correct.
6. In light of above discussion we are of the view that complainant has not proved her case for grant of relief as prayed accordingly this case is being dismissed on contest.    

                                                                                                                                                                                                                 S/d

(J.P.N. Pandey)

                                                                                      President

                                                                                                                                                                                                              S/d

                                                                                                  (Baby Kumari)

                                                                                       Member