Complainant through Lrd. Adv. Ghone
Opponent through Lrd Adv. Gaikwad
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Per : Mr. V. P. Utpat, President Place : PUNE
// J U D G M E N T //
(06/12/2013)
This complaint is filed by consumer for deficiency in service against the insurance company, who has wrongly repudiated the mediclaim of the complainant, under section 12 of the Consumer Protection Act, 1986. The brief facts are as follows,
1] The complainant is a resident of Paud Road, Pune. She herself and her husband have obtained mediclaim insurance policy from the opponent from 05/05/2003 and it was renewed regularly from time to time. It was lastly renewed for the period from 05/05/2008 to 04/05/2009. At the time of renewal, she was asked to undergo various tests and accordingly after undergoing all the necessary tests to the satisfaction of the opponent, the policy was renewed for Rs. 1,50,000/-. The premium for the said policy was paid by the complainant.
On 12/04/2009, the complainant was suffering from severe headache and giddiness. Such type of ailment never experienced by her before the said incident. She rushed to the hospital. After examination and clinical tests, she was admitted in the hospital and C.T. scan was taken and she took treatment in Joshi hospital from 13/4/2009 to 17/4/2009. Then she has submitted her claim to the opponent along with the necessary documents. But her claim was wrongly repudiated by the opponent. Hence, she has issued notice to the opponent through Advocate and asked reimbursement of medical expenses as well as compensation. The delay was caused by her for filing the present complaint due to non co-operation of the opponent. As the claim is not settled by the opponent, there is continuous cause of action. The complainant has asked compensation of Rs. 28,000/- i.e. reimbursement of medical expenses and cost of the proceeding, as
well as compensation on the ground of mental and physical sufferings and for deficiency in service.
2] The opponent resisted the claim by filing written version. All the contents of the complaint are flatly denied by the opponent. It is specifically denied that the opponent has caused deficiency in service. It is the case of the opponent that the complainant has committed breach of conditions of the policy. In view of clause no. 4.1 of the policy, the complainant is not entitled for compensation, as the disease for which medical treatment was taken, was aggravated form of pre-existing disease. Hence, the complainant is not entitled for compensation. It is also contended that the complainant has made excessive claim and alternatively it is contended that the complainant is entitled for an amount of Rs. 24,036/- only and not an amount of Rs. 28,000/- as claimed by the complainant. The opponent has prayed for dismissal of the complaint.
3] After scrutinizing the documentary evidence, which is produced before this Forum, hearing the arguments of both the counsels and considering pleadings, the following points arise for my determination. The points, findings and the reasons thereon are as follows-
Sr.No. | POINTS | FINDINGS |
1. | Whether complainant has proved that, the opponent has committed deficiency in service by wrongly repudiating mediclaim of the complainant? | In the affirmative |
2. | What order? | Complaint is partly allowed. |
REASONS :-
4] The undisputed facts between the parties are that the complainant and her husband have obtained insurance policy from the opponent since 05/05/2003 till 04/05/2009. It is not in much dispute that the complainant has paid premium of mediclaim insurance policy regularly and the policy was valid at the time of alleged medical treatment. The sole contention of the opponent for repudiating the mediclaim is that, there is breach of condition of policy, as the complainant has suppressed pre-existing disease and hence she is not entitled for insurance claim. It is the case of the opponent that the headache and the giddiness are the aggravation of hypertension and there is reference of hypertension in clause no. 4.1. Hence, the complainant is not entitled for insurance claim. The complainant has produced voluminous documents. It reveals from the same that the complainant was operated in the year 2003 and that has no concern with the disease for which she took treatment in the year 2009. The opponent has failed to bring on record that the disease, for which the complainant took treatment, had any nexus with the hypertension, which is excluded from clause no. 4.1. Moreover, it reveals from clause no. 4.1 that, on payment of additional premium, which is compulsory for persons suffering from the pre-existing conditions of Diabetes mellitus and Hypertension these specific pre-existing conditions are covered in certain manner. In such circumstances, I held that the disease, which was caused to the complainant, was covered by mediclaim insurance policy and the opponent is bound to settle the claim. The complainant has claimed an amount of Rs. 28,000/- as a reimbursement bill and other charges, but not produced bill for the same. The opponent has agreed in para 14 of the written version that the complainant has spent an amount of Rs. 24,036/-. In such circumstances, I held that the complainant is entitled for Rs. 24,036/- for mediclaim insurance. The complainant is entitled for compensation on the ground of physical and mental sufferings to the tune of Rs. 5,000/- and Rs. 2,000/- for the cost of the proceeding. I answer the points accordingly and pass the following order.
** ORDER **
1. Complaint is partly allowed.
2. It is hereby declared that the opponent has
caused deficiency in service by repudiating
mediclaim of the complainant.
3. The opponent is directed to pay an amount
of Rs. 24,036/- (Rs. Twenty Four Thousand
Thirty Six only), an amount of Rs. 5, 000/-
(Rs. Five Thousand only) towards compensation
for mental and physical sufferings and an
amount of Rs. 2,000/-(Rs. Two Thousand only)
by way of cost of litigation to the complainant,
within six weeks from the date of receipt of copy
of this order.
On failure to pay an amount of Rs. 24,036/-
within six weeks from the date of receipt of the
order, the complainant is entitled to receive
interest @ 9% p.a. on the said amount from the
date of filing of the complaint till its realization.
4. Copies of this order be furnished to the parties
free of cost.
5. Parties are directed to collect the sets,
which were provided for Members within
one month from the date of order, otherwise
those will be destroyed.
Place – Pune
Date- 06/12/2013
