Haryana

StateCommission

A/533/2016

UNITED INDIA INSURANCE CO. - Complainant(s)

Versus

VIPIN KUMAR GRG - Opp.Party(s)

NITIN GUPTA

16 Nov 2016

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                       

First Appeal No.   533 of 2016

Date of Institution: 10.06.2016

Date of Decision:   16.11.2016

 

1.      United India Insurance Company Limited, 68/1, Janpath, New Delhi -110001, New Delhi through its Branch Manager.

2.      United India Insurance Company Limited, Janpath, Branch Office at Champa Bhawan, Palwal (Opposite Krishan Sweets, Palwal), Tehsil and District Palwal through its Branch Manager.

 

          Both the appellants are now represented through the duly authorized signatory of Regional Office, SCO No.123-124, Sector 17B, Chandigarh.

                             Appellants-Opposite Party No.1

 

Versus

1.      Vipin Kumar Garg son of late Sh. Dharamvir Garg son of Bhajan Lal, resident of Kalra Colony, Near Geeta Bhawan, Palwal, Tehsil and District Palwal

2.      Lalit Kumar Garg son of late Sh. Dharamvir Garg son of Bhajan Lal, resident of Kalra Colony, Near Geeta Bhawan, Palwal, Tehsil and District Palwal.

Respondents-Complainants

3.      Medsave Health Care (TPA) Limited, Delhi, F-701A, Lado Sarai, Mehrauli, New Delhi -110030 through its Manager.

                                      Respondent-Opposite Party No.2

 

 

CORAM:             Hon’ble Mr. Justice Nawab Singh, President.

                             Mr. B.M. Bedi, Judicial Member.

                             Mr. Diwan Singh Chauhan, Member.                                                                                                                                           

Present:               Shri Nitin Gupta, Advocate for appellants.

                             Shri Johan Kumar, Advocate for the respondents-complainants

                             (Service of respondent-opposite party No.2 dispensed with vide order dated August 31^st, 2016.

 

                                                   O R D E R

 

NAWAB SINGH, J (ORAL)

 

          This appeal has been filed by United India Insurance Company Limited and another-opposite party No.1 (for short ‘Insurance Company’) against the order dated March 11^th, 2016 passed by District Consumer Disputes Redressal Forum, Palwal (for short ‘District Forum’) whereby complaint filed by Vipin Kumar Garg and Lalit Garg-complainants was accepted. For ready reference, operative part of the order is reproduced as under:-

“(i)     To refund the amount of mediclaim/Medishield Bills to the tune of Rs.2,37,387/- pertaining to the treatment of the deceased Smt. Geeta Devi during the currency of Mediclaim insurance policy (the treatment which she got from two hospitals i.e. Holy Family Hospital, New Delhi and Sarvodaya Hospital, Faridabad) with interest @ per annum to the complainant from July 15^th, 2013 (date of repudiation of second claim is within 105 days from the date of discharge from first hospital which is continuous period of illness as per policy clause Annexure R on page 1) till realization.

(ii)      To pay compensation for mental agony, tension, harassment, financial loss and wastage of precious time and not providing sufficient services and adopting unfair trade practice to the tune of Rs.10,000/- as well as litigation expenses to the tune of Rs.5500/-.”

               

2.      Dharamvir Garg and his wife Smt. Geeta Devi (hereinafter referred to as ‘Insured’)-parents of complainants, purchased Tailor Made Group Mediclaim and Personal Accident Insurance Policy (Annexure C1) from the Insurance Company for the period September 09^th, 2011 to September 08^th, 2012.  The sum insured was Rs.2,50,001/-.  The policy was renewed from September 09^th, 2012 to September 08^th, 2013.  Smt. Geeta Devi fell ill on August 27^th, 2012. She took treatment from Holy Family Hospital, Delhi and Sarvodaya Hospital, Faridabad.  She paid Rs.1,37,311/- to Holy Family Hospital and Rs.1,01,676/- to Sarvodaya Hospital, Faridabad.  The claim submitted by Smt. Geeta Devi was repudiated by the Insurance Company. Aggrieved thereof, the complainant filed complaint under Section 12 of the Consumer Protection Act, 1986. 

3.      In written version, Insurance Company pleaded that on scrutinizing the claim documents, Medsave Health Care (P) Limited-TPA raised queries on October 30^th, 2012 to submit the record of the treatment taken by Geeta Devi at AIIMS to rule out that there was any pre-existing disease prior to the purchase of the policy but the required documents were not submitted to the TPA.

4.      The only question arises for determination is whether Smt. Geeta Devi had suppressed any material fact from the Insurance Company at the time of filling of proposal form?

5.      Indisputably, Smt. Geeta Devi purchased Tailor Made Group Mediclaim and Personal Accident Insurance Policy (Annexure C1) from the Insurance Company. She was admitted in Holy Family Hospital, New Delhi vide Discharge Summary (Annexure A-2). Insurance Company has relied upon a certificate dated October 13^th, 2012 (Annexure A-4) issued by Holy Family Hospital, New Delhi stating that Smt. Geeta Devi was a known case of Multi System Atrophy, diagnosed at AIIMS-details not known.  From this certificate, it is not clear that on which date, she was diagnosed as a case of Multi System Atrophy at AIIMS.  So, from this piece of evidence, it cannot be said that Smt. Geeta Devi was having any pre-existing disease. This being so, the Insurance Company has wrongly repudiated the claim of complainants.

6.      Learned counsel for the Insurance Company has stated that that before filing the present complaint, the complainants earlier approached Permanent Lok Adalat for settlement of their claim.  The District Forum fell in error in awarding the amount alongwith interest from the date of repudiation of claim whereas it should have been from the date of filing of the complaint. 

7.      Submission being convincing, the Insurance Company is directed to pay Rs.2,37,387/- alongwith interest at the rate of 9% per annum to the complainants from the date of filing of the complaint, that is, July 14^th, 2015 till realization; Rs.10,000/- as compensation and Rs.5500/- litigation expenses. The appeal is disposed of accordingly and the impugned order is modified in the manner indicated above.

8.      The statutory amount of Rs.25,000/- deposited at the time of filing of appeal be refunded to the complainants against proper receipt and identification in accordance with rules.

 

Announced 16.11.2016

(Diwan Singh Chauhan) Member

(B.M. Bedi) Judicial Member

(Nawab Singh) President

U.K