Back
UTTARAKHAND STATE CONSUMER DISPUTES REDRESSAL COMMISSION, DEHRADUN
Ms. Kumkum Rani, Judicial Member II and Mr. B.S. Manral, Member
National Insurance Co. Ltd. – Appellant
versus
Jasvir Singh and Ors. – Respondents
First Appeal No.74 of 2017
Decided on 9.2.2023
Consumer Protection Act, 1986 – S.15[Consumer Protection Act, 2019 – S.41] – Appeal Against order of District Commission - Services – Insurance – Repudiation of Claim - not justified – no proof of Insurance Company – Conducting test – To determine pre-existing disease - Whether there had been any breach of any terms and conditions of the policy in question, or whether the respondent No. 1 – complainant has not disclosed to the insurance company about his pre-existing disease - On record, the appellant – insurance company has not submitted any such document of any such doctor, who has ever medically examined the insured and prescribed the medicine of diabetic disease during such last four years - Thus, a perusal of all the medical papers has revealed that the insured – respondent No. 1 – complainant was not suffering from such pre-existing disease (Diabetic) as averred in the grounds of appeal - District Commission has properly and legally passed the impugned judgment awarding Rs. One Lakh as insured amount. So far as the interest amount is concerned, the insured amount should be paid within 30 days and in default, the respondent No. 1 – complainant shall be entitled to get interest from the date of filing of the complaint till its actual realization. No modification as to other aspect. Appeal partly allowed to the above extent - Appeal is partly allowed to such extent and the impugned judgment shall be deemed modified to the above extent. Appellant – Insurance Company shall pay Rs. One Lakh to the respondent No. 1 – complainant within a period of 30 days. [Paras 16 to 25].
Result: Appeal partly allowed.
ORDER
Kumkum Rani, Judicial Member II—This appeal under Section 15 of the Consumer Protection Act, 1986 has been directed against the judgment and order dated 15.04.2017 passed by the learned District Consumer Disputes Redressal Forum, Udham Singh Nagar (hereinafter to be referred as the District Commission) in consumer complaint No. 25 of 2013 styled as Sh. Jasvir Singh Vs. National Insurance Co. Ltd. and others, wherein and whereby the complaint case was allowed directing the opposite party Nos.1 & 2 to pay insured amount to the tune of Rs. 1,00,000/- alongwith simple interest @ 6% per annum from the date of filing the complaint till its actual payment as well as Rs. 5,000/- as litigation charges to the complainant.
2. The facts giving rise to the present appeal, in brief, are as such that the respondent No. 1 – complainant had filed a complaint case No. 25 of 2013 before the District Commission, Udham Singh Nagar claiming a compensation of Rs. 2,16,200/- for operation charges and Rs. 50,000/- for Laboratory Test expenses, Rs. 1,00,000/- for damages, Rs. 35,000/- for other expenses and Rs. 25,000/- towards litigation expenses. It is further averred that the complainant has taken a Baroda Health Hospitalization Benefit Policy bearing policy No. 461803/48/11/8500000095 from the opposite party No. 3 (Bank of Baroda) with a premium of Rs. 1,716/- which was valid with effect from. 29.08.2011 to 28.08.2012; subsequently the complaint again got renewal of the said insurance policy after payment of Rs. 1,748/- on dated 24.08.2012, which was valid from 29.08.2012 to 28.08.2013 and the renewed policy number was 461803/48/12/8500000111. The complainant felt some pain in his chest and examined himself from the local doctor. As per the advice of the doctor, the complainant was medically examined by the doctors of Medanta The Medicity Hospital on dated 24.09.2012, where he was advised to get operated immediately; he was admitted on 24.09.2012 in the same hospital at Gurgaon and after conducting all the tests and medical check-up, operation of his chest was conducted. He was discharged from the above said hospital ‘Medanta The Medicity Hospital on 02.10.2012. The complainant has incurred Rs.2,16,200/- in his treatment and all the bills of his medical expenses were prepared in the name of Global Health Pvt. Ltd., which was paid by the complainant. The complainant immediately informed the opposite parties about his treatment and the operation, thereupon the opposite parties went to the hospital and checked up all the record of his medical check-up / operation, but the opposite parties did not pay the insured amount to him inspite of several requests; when the complainant has contacted the opposite parties in their office, then they have given a repudiation letter dated 26.09.2012, whereby his claim was repudiated. By such repudiation of his claim, the complainant had to suffer mental as well as well physical agony, therefore, he is entitled to get Rs. One Lakh for such compensation. The opposite parties are not agreed to pay the insured amount, hence, the complainant has filed a complaint case before the District Commission.
3 The opposite party No. 1 – appellant has averred in its written statement before the District Commission that as per the terms and conditions of the mediclaim policy, the claim of the respondent No. 1 – complainant was repudiated on the ground that the patient was admitted with the complaint of chest pain; patient was diagnosed as a case of Diabetes Mellitus, CAD and Unstable Angina and underwent Coronary Angiography (patient is a known Diabetic on oral anti-hypoglycemic agents since the last four years). As per the Clause No. 4.1 of the mediclaim policy, which clearly mentioned that All the pre-existing disease shall be covered if the policy have been continuously in force for 36 months. Any complication arises from pre-existing ailment / disease / injury will be considered as part of the pre-existing health condition
Medically examined - insurance company has not submitted any such document of any such doctor, who has ever medically examined the insured and prescribed the medicine of diabetic disease during such ....
(1) Health Insurance Policy [Mediclaim Policy] – Repudiation based on exclusion clause which was not communicated to insured can never be pressed into service to deprive insured from claiming relief.....
Pre-existing disease – life assured has deliberately concealed the true facts about his state of health and suppressed his pre-existing disease.
Existence of Disease – There is no reason for the insurance company to connect the existence of diabetes with the disease for which treatment has been taken.
(1) Proof of delivery - In the absence of proof of delivery, therefore, Commission cannot rely solely on the Respondent’s statement before the District Commission that it had duly supplied the terms ....
(1) Significance of Policy Documentation – Policy documents issued by the appellant contained a “dash” in the column for pre-existing diseases. This serves as an admission by the insurer that no such....
An indispensable Tool for Legal Professionals, Endorsed by Various High Court and Judicial Officers
Please visit our Training & Support
Center or Contact Us for assistance
Scan Me!
India’s Legal research and Law Firm App, Download now!
For Daily Legal Updates, Join us on :
Back to top
