ORDER
Date of order 11 -10-2017
Upendra Jha,Member
This appeal is directed against the order dated 11-01-2016 passed by the District Consumer Forum, Muzaffarpur in Complaint Case No.70 of 2011 by which the complaint of the complainant was dismissed on the ground that the complainant has been paid expenses for his Coronary Artery Surgery by the Insurer hence, separate claim for Rs. 2, 00,000/- (Rupees two lacs only) is not maintainable.
2. Briefly stated the case is that the complainant being a Senior Citizen between the age group of 60 years to 90 years,took this policy Varisth Mediclaim for Senior Citizen Insurance Policy for Mediclaim Rs.1,00,000/- and for critical illness Rs.2,00,000/- (Rupees two lacs only) on payment of Rs.8,728/- as premium including special excess premium of 10-20% as the appellant had declared condition of Hypertension and Diabetes on 29-06-2007. It was renewed time to time from 29-06-2009 to 28-06-2010. Policy was accordingly issued. The appellant suffered chest pain, so he was admitted in Heart Hospital, Chandralay, Patna on 29-10-2009. Angeography was done on 31-10-2009. The Insurance Company was informed and they sought for estimate of operation. Coronary Artery Bypass Grating Surgery of the appellant was performed on 04-09-2009 and he was discharged on 11-10-2009. Due to complication he was re-admitted in the Hospital on 14-11-2009 and discharged on 15-11-2009. He filed claim before the Insurance Company along with Bills and vouchers on 25-01-2010. Till 10-11-2009 the bill was for Rs.1,56,610/- (Rupees one lacs, fifty six thousand and four hundred ten only) out of which the Insurance Company paid Rs. 79,200/- but critical illness amount Rs.2,00,000/- (Rupees two lacs only) was with held and the Company repudiated the claim on 26-03-2011 on the ground that Coronary Artery Disease were present prior to inception of policy. Then, complaint was filed before the District Forum. Insurance Company contested the case. The District Forum passed the impugned order against which this appeal is preferred.
3. Respective written notes of arguments have been filed by the parties. Heard and perused the District Forum order.
4. District Forum held that the complainant is not entitled for payment of Rs. 2,00,000/-(Rupees two lacs only) as he has already paid the expenses of his treatment. Hence, the complaint was dismissed.
5. The counsel for the appellant submits that he obtained Insurance Policy which has two parts, First part hospitalization expenses up to Rs.1,00,000/- and 2nd part for ‘critical illness’ sum insured Rs.2,00,000/-(Rupees two lacs only). He paid 10-20% excess premium for both parts of this policy because the appellant was suffering from Diabetes and Hypertension; Coronary Artery Bypass Surgery was performed to the appellant on 04-09-2009. He was reemburshed Rs. 79,200/- out of Rs.1, 56,610/- (Rupees one lacs, fifty six thousand and four hundred ten only) Hospital Bill. He suffered first time Coronary Artery Disease in 10/2009. The appellant was not paid the claim of Rs.2, 00,000/- (Rupees two lacs only) for that he is entitled. But the District Forum dismissed this claim which is not sustainable.
6. The counsel for the respondent submits that the claim of Rs. 2,00,000/- (Rupees two lacs only) of the complainant was repudiated on the ground that the appellant had Coronary Artery disease from very inception of policy. The complainant has not proved that he was not suffering from this disease before taking policy. This policy covers ‘Coronary Artery Surgery’ and not ‘Coronary Artery disease’. The amount of surgery has already been paid to him. He is not entitled to get’Cornary Artery disease’. He has been intimated for that District Forum order is just and proper. It needs no interference.
7. Having considered the submissions of parties and on perusal of the order passed by the District Forum, it is admitted fact that the appellant had obtained Insurance Policy for Varisth Mediclaim for Senior Citizen. Rs.1,00,000/-(Rupees one lac only) for Mediclaim and Rs. 2,00,000/-(Rupees two lacs only) for critical illness. During policy period, the appellant was performed the Coronary Artery Bypass Surgery on 04-09-2009 and incurred an expenditure of Rs.1, 56,610/-(Rupees one lacs, fifty six thousand and four hundred ten only) in his treatment. The only dispute between the parties is whether the appellant was suffering from Diabetes and Hypertension prior to obtaining policy. The O.P.-respondent has not produced any admissible and reliable evidence to prove that the appellant was suffering from above disease. The Hon’ble Apex Court in the case of L.I.C. vs. G.M. Channebasamns reported in 1991 (1) SCC 357 has held that the burden of proof goes to the Insurance Company. In view of the above finding of the Hon’ble Apex Court the repudiation of claim by the Insurance Company is not proper and order passed by the District Forum cannot be sustained. Hence, the District Forum order is set aside and the appeal is allowed. The respondent-O.P. is directed to pay the balance amount Rs. 1,56,610/-79,200=77,410/- with 6% interest from the date of filing complaint and a compensation with litigation cost Rs. 10,000/- be paid within two months from the receipt of this order.
S.K.Sinha Renu Sinha Upendra Jha
President Member (F) Member (M)
Anita
