A/16/589

1

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

MAHARASHTRA, MUMBAI

Appeal No.A/16/589

(Arisen out of order dtd.15/03/2016 in Complaint No.189 of 2014 of Central

Mumbai District Consumer Disputes Redressal Forum)

Future General Insurance Co. Ltd.,

Through its Manager,

Office at – India Bulls Finance Centre,

Tower No.1, 12^th & 15^th Floor,

Senapati Bapat Marg, Elphinston Road (West), .... Appellant/

Mumbai – 400 013, Maharashtra State.

(Original Opponent)

Versus

Miss. Pushpa H. Tandale,

R/at – 8C/602, Neelyog Tower,

Dhanjiwadi, Nr. W.E. Highway

Malad (East), Mumbai – 400 087,

.... Respondent/

Maharashtra, Mumbai.

(Original Complainant)

BEFORE: Mr.D.R. Shirasao, Judicial Presiding Member

Mr.A.K. Zade, Member

PRESENT: Advocate Shri. S.R.Singh for Appellant.

Advocate Smt.Swagate Singh for Respondent.

ORDER

Per Hon’ble Mr.A.K. Zade – Member:

1)

This appeal is filed against the impugned order by which this Appellant-

Original Opponent was directed to pay Rs.3,49,000/- to the Complainant with

interest @ 9% p.a. from the date of filing complaint till realization and also to

pay Rs.15,000/- towards compensation for mental agony and Rs.10,000/-

towards cost of the complaint.

2)

As per Complainant, facts of the case are as follows –

Complainant took medical insurance policy from Opponent for the

period from 15/12/2009 to 14/12/2010 for the insured sum of Rs.3,00,000/-

A/16/589

2

and the same was renewed in subsequent years. Prior to it, Complainant was

insured with the other Insurance Company i.e. New India Assurance Co. Ltd.

for 11 years and had regular check-ups for the said medical policy and the said

policy was transferred to Opponent in the year 2009, as she was promised by

the concerned agent that she will be given complete portability and her

connectivity benefit will not be affected. As per Complainant, on 28/12/2011,

she was diagnosed with Congenital Internal Heart Defect and was operated on

03/01/2012. After getting discharge from the hospital, she submitted her

insurance claim to the Opponent. However, Opponent repudiated her insurance

claim by letter dtd.31/01/2012 stating that her claim did not fall under the

purview of the policy and was accordingly rejected. Complainant thereafter

approached the Ombudsman who also rejected complaint of the Complainant.

Thereafter, Complainant sent legal notice to Opponent which was replied by

Opponent. However, as there was no positive response from Opponent,

Complainant filed subject complaint before the Ld.District Forum.

3)

Opponent contested complaint by submitting written statement. As per

Opponent, Complainant was suffering from congenital defect of the Atrial

Septal Defect (ASD) and the Complainant underwent corrective surgery

known as “Transcatheter Closure” and was hospitalized from 02/01/2012 to

04/01/2012 for the same. Opponent submitted that Complainant was suffering

from congenital disease which was excluded from scope of the policy cover as

per exclusion clause of the policy and also it was prominently stated on the

face of the policy that any claim arising or related to consequences of pre-

existing diseases was excluded from the scope of policy cover and for those

reasons Complainant could not ask for any relief on mistaken belief on her

part. Opponent also denied that the alleged agent had stated that there would

be complete portability of the risk, if she transfers policy to Opponent from

New India Assurance Company. Opponent had offered to cover the risk under

the relevant policy only subject to terms and conditions of the same which

A/16/589

3

were more particularly described therein. After going through the pleadings,

affidavits of evidence, written arguments and hearing arguments on behalf of

the parties, the Ld.District forum passed the impugned order.

4)

Appellant filed this appeal on the ground that there is error apparent in

the impugned order as claim was allowed even though the Respondent was not

covered in respect of Congenital (Heart) Diseas

Click Here to Read the rest of this document