BEFORE THE  DIST. CONSUMERS DISPUTES REDRESSAL FORUM;  DHARWAD.

DATE: 22^nd July 2015        

PRESENT:

1) Shri B.H.Shreeharsha       : President

2) Smt.M.Vijayalaxmi             : Member 

Complaint No.:128/2015    

Complainant/s:      

Veeranagouda S/o. Digeppa Shitikond,    Age: 58 years,         Occ: Pvt. Practice,  R/o.Mallikarjun Nilaya, H.No.25A, 8^th Cross, Chandranatha Nagar, Hubli 560032.  

(By Sri.B.V.Hebbal, Adv.)

v/s

Respondent/s:

1. The Oriental Insurance Co. Ltd., #6, 7^th Main, 80 ft. Road, 3^rd Block, Koramangala, Bangaluru-34. R/by The Divisional Manager, Oriental Insurance Co. Ltd., Enkay Complex, Keshwapur, Hubli

2. Medi Assist India TPAP Ltd., No.45-A, Green Arch Building, 1^st Main Road, Next to Park View Restaurant, Mini Forest Service Lane, J.P.Nagar, 3^rd Phase, Bangaluru-78.

(By Sri.S.G.Patil, 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.71320/- towards medical treatment & medical charges with interest @18% from the date of petition, to pay Rs.25,000/- towards damages, Rs.10,000/- towards compensation for mental agony, Rs.10000/- 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, the complainant had taken Mediclaim policy through Punjab National Bank of the policy belongs to the respondent bearing No.423101/48/2015/706 by paying premium of Rs.4620/- covering the risk from 07.06.2014 to 16.06.2015. All of a sudden the complainant developed pain in lumber spine on 18.11.2014. For that the complainant underwent operation at Balaji Institute of Neuro Science & Trauma, Hubli & spent Rs.71,320/- for treatment and medicines and discharged on 20.11.2014. Thereafter along with all documents claim was submitted to the respondent.1 on 28.11.2014 but the same was rejected by the respondent.1 with a repudiation letter 24.12.2014 which was received by the complainant on 02.02.2015 with the reason the diseases were pre existing at the time of proposal & repudiation is made as per exclusion clause 4.1. The non payment of the claim amounts to deficiency in service. Hence, the complainant has filed the instant complaint praying for the relief as sought.

3.     In response to the notice issued from this Forum the respondents appeared and filed the written version in detail denying and disputing the complaint averments. While admits the issuance of the policy & existence of the policy to the date but respondent denied other averments of deficiency in service and unfair trade practice submitting that the repudiation is made on valid grounds in accordance with the clause.4.1 of the policy condition and also for the reason the complainant had underwent the operation for the pre existing disease and for the reason at the time of proposal the same was not disclosed and further concluded the claim is within the year & as there is no history of previous insurance their repudiation is justified & prays for dismissal of the complaint.

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 ?

Both have admits sworn to evidence affidavit & have relied on document. The respondent also relied on citations. Heard. Perused the records.

Finding on points is as under.

1. Negative 
2. Negative  
3. As per order

Reasons

Points 1 and 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, the complainant had obtained the policy and the said policy is covering the risk for the period.

6.     Now the question to be determined is, whether the complainant is eligible for the claim under the policy and the repudiation of the same by the respondent amounts to deficiency in service, if so, for what relief the complainant is entitled.

7.     Apart from pleadings and evidence at the time of argument the respondent taken this Forum to the policy schedule 4.1 and 4.2 & its sub clause.20. Whereas in the said condition clause 4.2 (xx) it is stated that for the concerned surgery for which the complainant underwent and to have claim the policy should have rund for 2 years. The impugned policy covered the risk between 07.01.2014 to 06.06.2015. On perusal of the policy no previous history of coverage of the policy risk earlier to instant policy. The complainant went under operation on 19.11.2014 i.e. within a period of one year of commencement of the policy. Hence, the present claim comes within the exclusive clause.4.1 and 4.2. Hence, complainant is not entitled for the claim under the insurance policy as such the complainant erred in establishing the deficiency in service against the respondent interalia the respondent established his justification of repudiation of claim. Hence, respondent is not liable to pay any claim or compensation. So also complainant is not entitled for the reliefs which have been claimed.

8.     In view of the above discussions we have arrived and proceed to held issue.1 and 2 in negative.

9.     Point.3: In view of the finding on points 1 and 2 proceeded to pass the following 

Order

        The complaint is dismissed. No order as to costs.

(Dictated to steno, transcribed by him and edited by us and pronounced in the open Forum on this day on 22^nd day of July 2015)

(Smt.M.Vijayalaxmi)                                      (Sri.B.H.Shreeharsha)

Member                                                President

Dist.Consumer Forum                                    Dist.Consumer Forum

MSR