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K.S.P
A-14-1176
Page 1 of 14
BEFORE THE CONSUMER DISPUTES REDRESSAL COMMISSION,
GUJARAT STATE AT AHMEDABAD.
Court-3
APPEAL NO. 1176 of 2014 Dt: 31.01.2022
Universal Sompo General Insurance Co. Ltd.
201-208, Crystal Plaza,
Opp. Infinity Mall, Link Road,
Andheri (West), Mumbai.
…Appellant
Vs.
1. Mahendra M. Upadhyay
12/B, Star Apartment,
Opp. Nalanda Complex,
Vastrapur, Ahmedabad.
2. Indian Overseas bank
Thaltej Branch, Nr. Drive-In Cinema,
Ahemedabad.
3. Tik Health Care TPA Pvt. Ltd.
3rd Floor, Mahakant Building,
Opp. V. S. Hospital,
Ellisbridge, Ahmedabad.
...Respondents
Appearance: Mr. Darshil Parikh, Ld. Advocate for Mr. V. P.
Nanavaty, Ld. Advocate for the Appellant
Mr. Milan Dudhiya, Ld. Advocate for the
Respondent No.1.
Coram: (Shri S. N. Vakil, Member)
(Smt. J. Y. Shukla, Member)
Order by Shri S. N. Vakil, Member
1. This Appeal is by the Insurance Company.
2. The Complainant – Mahendra M. Upadhyay filed Consumer Complaint
being CC No. 346/2012 with CDRF, Ahmedabad City (Addi.) against the
Indian Overseas Bank, Universal Sompo General Insurance Co. Ltd. and
Details
DD
MM
YY
Date of Judgment
31 01
2022 Date of filling
28 05
2014 Duration
03 08
K.S.P
A-14-1176
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Tik Health Care TPA Pvt. Ltd that he having the savings account with
Indian Overseas Bank – Opponent No.1, the insurance company insisted
through its officer to take medical insurance of his family. The bank
offered IOB Health care plus insurance policy. The complainant took the
policy on 02.01.2010 for himself and his wife for 5,00,000/- at premium
of Rs. 7,174/-, which was renewed from 04.01.2011 to 03.01.2012. He
was admitted on 06.07.2010 under the treatment of Dr. Vinay Bhomia at
Sanjivani Super Speciality Hospitals Pvt. Ltd., Vastrapur, Ahmedabad
due to pneumonia and was kept in the hospital for 10 days. The
expenses were Rs. 2,03,667/- on 26.07.2011. He was having angina pain
and was admitted to CIMS Hospital Pvt. Ltd., and after angiography Dr.
Urmil Shah diagnosed that he was suffering from Coronary Artery
Disease, Procedure of stenting was done and was discharged on
29.07.2011, the expenses were Rs. 2,92,851/-. The complainant lodged
the claim for total amount of Rs. 4,96,518/- together with papers and
documents with the insurance company. The insurance company has
repudiated the genuine claim of the complainant stating that “disease
DM is 20 years which is pre-existing and also not disclosed in the
proposal form. Hence, the claim is medically repudiated under the clause
1 and non-disclosure of material facts as per the policy conditions.” It
has been repudiated on false and flimsy ground. The complainant fell ill
and suffered pneumonia in month of July, 2011 and was under
treatment of Dr. Bhomia, thereafter heart trouble had started and heart
treatment in CIMS Hospital was taken but the insurance company has
with malafide intentions repudiated the claim. The insurance company
has not even replied to notice dated 01.03.2012. For this deficiency he
claims for Rs. 4,96,518/- with 9% interest from the date of repudiation
K.S.P
A-14-1176
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i.e. 05.03.2012, Rs. 25,000/- towards mental harassment and Rs.
10,000/- towards costs.
3. The defence of the Insurance Company – Opponent No.2 vide written
version is of total denial. It denies that the officers of the bank insisted
the complainant to take medical insurance of the opponent No.2 for his
family. It also denies that the bank had offered IOB Health care plus
insurance policy to the complainant. The complainant was not only
admitted in Sanjivani Super Specialty Hospitals Pvt. Ltd. for the
treatment of pneumonia but as per the discharge summary of the said
hospital he was admitted there for the treatment of left LZ pneumonia +
Ant. Wall M.I. + Post Wall M.I. + LVF + DM. It is false to say that he was
admitted in the said hospital du
