Per Mr.B.S.Wasekar, Hon’ble President
1) The present complaint has been filed by the complainant u/s 12 of the Consumer Protection Act, 1986. According to the complainant, deceased Kamla Dilip Jain was his wife. She died on 5th April, 2011. She was insured with the opponents under DR CASH PLUS INSURANCE vide its Insurance Certificate No. CDA000 2179000100 for the period from 2nd March, 2010 to 1st March, 2011. Under this policy, the insured can get daily benefit of Rs.5,000/- for hospital treatment for the period of 14 days. The deceased Kamla had fever therefore she was advised to admit in the Lilavati Hospital. She was diagnosed as END STAGE RENAL DISEASE. She was in the hospital from 16th June, 2010 to 4th October, 2010. The complainant requested the opponents to settle the claim of Rs.95,000/-. The opponents issued letter dated 10th January, 2011 and repudiated the claim on the ground that kidney disease is not covered during the first year of policy and patient is known case as DM/HTN and it is pre existing disease. The repudiation by the opponents is wrong. Therefore, the complainant issued letter dated 25th January, 2011 and 31st March, 2011. As the opponents denied the claim, the complainant has filed this complaint for recovery of claim of Rs.95,000/-, mental harassment Rs.10,000/-, miscellaneous expenses of Rs.1,500/- and legal expenses of Rs.6,500/- with interest.
2) The opponents filed written statement. It is admitted that wife of the complainant deceased Kamla was insured with it and the said policy covered daily benefit of Rs.5,000/-. The said policy was subject to terms and conditions as stipulated in the policy. The wife of complainant was diagnosed as CHRONIC RENAL FAILURE-END STAGE-V. She was admitted from 16th June, 2010 to 4th July, 2010. During the investigation, it was transpired that the wife of complainant was suffering from Chronic Kidney Disease and Hypertension. As per the policy terms and conditions, this disease was excluded. Therefore, the claim was repudiated. The complainant is not entitled for the relief as claimed.
3) After hearing both the parties and after going though the record, following points arise for our consideration.
POINTS
Sr. No. | Points | Findings |
1) | Whether there is deficiency in service ? | No |
2) | Whether the complainant is entitled for relief the as claimed ? | No |
4) | What Order? | As per final order |
REASONS
4) As to Point No.1 & 2:- It is not disputed that wife of the complainant was insured with the opponents. The complainant himself has produced policy and terms and conditions of the policy. There is specific clause of exclusion. According to the opponents, during investigation, it was transpired that wife of the complainant was suffering from Chronic Renal Failure-End Stage-V. The complainant and the opponents have produced medical treatment papers of deceased. On perusal of it, it is clear that deceased Kamla was suffering from Chronic Renal Failure-End Stage-V. As per exclusion clause of the policy, kidney disease is excluded from the benefit. Considering this specific condition excluding the disease from the benefit, the complainant is not entitled for the relief as claimed. The Opponents have properly repudiated the claim.
5) The learned advocate for the complainant has submitted that earlier the opponents have given benefit to the complainant. Even if, it is presumed that earlier opponents have given benefit to the complainant still there is specific exclusion clause in the terms and conditions in the polity. These terms and conditions are produced by the complainant himself alongwith the policy. The policy is the contract in between the parties. Therefore, both the parties are bound to follow those terms and conditions. The learned advocate for the opponents has placed reliance on the judgment of the Hon’ble Supreme Court reported in IV(2009) CPJ 8 (SC) in the case of Satwant Kaur Sandhu –Versus- New India Assurance Company Limited decided on 10th July, 2009. In this judgment, the Hon’ble Supreme Court has laid down that insured is under obligation to make true and full disclosure within his knowledge. Suppression of material fact deprives the benefits. In the instant case before us, medical papers shows that the deceased was suffering from Chronic Renal Failure-End Stage-V. As the disease was chronic, it was necessary for the complainant to disclose it while taking policy. As per the terms and conditions of the policy, the complainant is not entitled for the benefit as claimed. Similar law is laid down by the Hon’ble National Commission in the judgment reported in II (2012) CPJ 272 (NC) in the case of Life Insurance Corporation of India –Versus- Kusum Patro decided on 19th March, 2012. In view of the above settled law of the Hon’ble Supreme Court and National Commission, repudiation of the claim by the opponents is proper. Therefore, the complainant is not entitled for the relief as claimed. Thus, there is no deficiency in service. Hence, we proceed to pass the following order.
ORDER
1) The complaint stands dismissed
2) Parties are left to bear their own costs.
3) Inform the parties accordingly.
Pronounced
Dated 18th December, 2013
