BEFORE THE DIST. CONSUMERS DISPUTES REDRESSAL FORUM; DHARWAD.
DATE: 12th April 2016
PRESENT:
1) Shri B.H.Shreeharsha : President
2) Smt.M.Vijayalaxmi : Member
Complaint No.: 321/2015
Complainant/s:
Dr.Veerappa s/o.Veeranna Pattar,
Age: 47 years, Occ:Doctor, R/o.Kulageri Cross (Khanapur S.K.) Tq.Badami, Dist.Bagalkot
(By Sri.B.S.Bhagavati, Adv.)
v/s
Respondent/s:
- The Branch Manager, Aviva Life Insurance Co. India Ltd., 3rd Floor, Bellad Building, Gokul Road, Near Banni Katti, Hubli, Dist.Dharwad.
- Aviva Life Insurance Co. India Ltd., 3rd Floor, Aviva Towers, Sector No.43, Opposite to DLF Gulf Cores, Gurgaon 122003, Stae:Haryana.
(By Sri.G.M.Kansogi, Adv.)
O R D E R
By: Shri. B.H.Shreeharsha : President.
1. The complainant has filed this complaint claiming for a direction to the respondents to pay Rs.3 lakhs along with interest @18% from the date of rejection of the claim till realization, to pay Rs.50,000/- as compensation towards deficiency in service, Rs.25,000/- compensation towards mental agony, Rs.15,000/- towards cost of the proceedings and to grant such other reliefs
Brief facts of the case are as under:
2. The case of the complainant is that, complainant is a doctor in profession and residing in the cause title address. On 20.06.2012 the complainant had insured his life with respondent under policy Life sealed advantage bearing no.ALA3113016. The said policy covered along with benefits by name Aviva Dread disease rider. From the date of commencement of the said policy the complainant came on paying annual premium and till the date he had paid all premium in time and kept the said policy in force. The complainant at different hospitals got checkup for his heart ailment. On 16.06.2014 the complainant went to KLE Hospital for checkup with regard to the heart ailment. Where at that hospital the doctor carried out several tests. Thereafter at the advise of the doctor KLE Hospital on 21.06.2014 the complainant went under coronary angiogram & had paid Rs.3,14,770/-. Since the policy in question covered with the risk of Aviva Dread disease rider to an extent of Rs.3 lakhs the complainant along with all medical documents submits claim to the respondent 1 claiming Rs.3 lakhs towards the expenses incurred. In turn the respondents through their letter dtd.24.07.2014 intimated the complainant rejecting the claim. The said letter is received by the complainant on 22.08.2014. The respondents with a sole intention not to pay the claim under the policy covering dread disease rider rejected the claim intentionally. The non payment of the claim amount amounts to deficiency in service as such aggrieved by the same complainant filed the instant complaint praying for the relief as sought.
3. Despite service of the notice the respondents remained absent. Hence, placed exparte. Thereafter one Sri.GMK Advocate along with memo of appearance filed I.A.1 seeking permission to appear by set asiding the order of placing respondent exparte. However this Forum with a due intention to give an opportunity to contest the matter allowed I.A. Despite giving ample opportunities the LC nor the respondents appeared and filed written version. Hence, it is taken no written version.
4. On the said pleadings the following points have arisen for consideration:
1. Whether complainant has proved that there was deficiency in service on the part of respondents ?
2. Whether complainant is entitled to the relief as claimed ?
3. To what relief the complainant is entitled ?
The complainant filed sworn to evidence affidavit, relied on documents. Apart from argument the complainant also filed notes of argument. Heard. Perused the records.
Finding on points is as under.
1. Affirmatively
2. Accordingly
3. As per order
R E A S O N S
P O I N T S 1 & 2
5. On going through the pleadings & evidence coupled with documents of both the parties it is evident that there is no dispute with regard to the fact, that the complainant had taken policy from the respondent covering the risk Aviva Dread disease rider.
6. Now the question to be determined is, whether rejection of the claim amounts to a deficiency in service, if so, for what relief the complainant is entitled.
7. Since the facts have been revealed in detail which requires no repetition.
8. As the respondent did not admits written version and led evidence the complaint averments stood unimpeached. Ex.C13 the proposal form reveals in detail the coverage of the risk, benefits, terms and conditions of the policy and also policy rider benefits. Ex.C3 to 12 without giving room for suspect reveals the complainant underwent coronary angiogram operation by spending Rs.3,14,770/-. The perusal of the documents Ex.C2 issued by the respondent dtd.24.07.2014 i.e. rejection of claim reads “after careful consideration of all the documents submitted by you, we would like to inform you that claim even does not meet the eligibility criteria as per our standard terms and conditions of the Dread disease benefits rider”. So also in the said rejection the meaning of heart attack is also given.
Heart attack- The death of portion of heart muscles as a result of inadequate blood supply and being evidenced by all 3 of the following
* A history of typical prolonged chest pain &
* New electrocardiograph (ECG) changes; and
* Significant elevation of cardiac enzymes above accepted laboratory levels of normal
- confirmation by a specialist approved by us may be required. Diagnosis of heart attack based solely on an ECG or on solely on blood test is excluded. We will not pay for other causes of sever non cardiac chest pain, heart failure or angina.
9. It is to be noted once the claim is rejected the burden shift on the person who disclaim the claim of the proposer. As already discussed supra despite service of notice and given opportunity the respondent did not chosen to contest the matter by protesting the claim and adduced corroborative evidence in support of disclaim.
10. The discharge card Ex.C11 supported with ECG report Ex.C6 & 10 & Case sheet reveals the complainant is suffered from Heart attack as mentioned in the standard terms and conditions of the proposal form under Aviva Dread Disease rider. Thereby it is evident that that the complainant underwent heart treatment in accordance with the Aviva Dread Disease rider policy risk & he is eligible for the claim. Non settlement of the claim amounts to a deficiency in service. Hence, complainant is entitled for the reliefs.
11. In view of the above discussions we have arrived and proceed to held issue.1 and 2 in affirmatively and accordingly .
12. Point.3: In view of the finding on points 1 and 2 proceeded to pass the following
O R D E R
Complaint is allowed in part. The respondents 1 and 2 jointly and severally directed to pay Rs.3 lakhs along with interest @9% P.A. from 24.07.2014 till realization along with Rs.2,000/- as compensation and Rs.1,000/- towards cost of the proceedings within 30 days from the date of receipt of copy of this order.
(Dictated to steno, transcribed by him and edited by us and pronounced in the open Forum on this day on 12th day of April 2016)
(Smt.M.Vijayalaxmi) (Sri.B.H.Shreeharsha)
Member President
Dist.Consumer Forum Dist.Consumer Forum
MSR
