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M.P.STATE CONSUMER DISPUTES REDRESSAL COMMISSION
PLOT NO. 76, ARERA HILLS, BHOPAL (M.P.)
Appeal No.11/2010
Sunil Kumar Shivhare
… Appellant
Vs.
Bajaj Allianz Life Insurance Co. Ltd.
… Respondents
BEFORE;
HON’BLE SHRI JUSTICE RAKESH SAKSENA, PRESIDENT
HON’BLE SMT. NEERJA SINGH, MEMBER
COUNSEL FOR THE PARTIES:
NONE FOR APPELLANT.
MS. SANGEETA MOHARIR, LEARNED CUNSEL FOR RESPONDENTS.
O R D E R
( PASSED ON 16 .09.2015 )
The following order of the Bench was delivered by
Smt. Neerja Singh, Member.
This appeal is by the complainant, aggrieved by
the order dated 09.11.09, passed by District Consumer
Disputes Redressal Forum, Seoni, dismissing his complaint
against the respondent, Bajaj Allianz Life Insurance Co. Ltd.
(hereinafter referred to as the insurance company) in CC
No. 18/09.
2.
The facts, in brief, are that the appellant took a
Mediclaim insurance policy from the respondent Insurance
Company on 7.11.07, for the sum insured Rs.1,00,000/- . He
: 2 :
states that he fell sick on 3.1.08 and had severe pain in his
back. He consulted a doctor on 4.2.08. Later, he was
admitted in Satayu hospital in Nagpur, where he had to
undergo a total hip transplant. He was discharged on
20.5.08. The appellant states that he incurred expenses of
more than Rs.1,00,000/- in the treatment and he still has to
continue taking drugs. He filed a claim with the respondent
Insurance Company who asked for the original documents.
He gave them all the documents, but they repudiated the
claim on 17.7.08.
3.
The respondent Insurance Company have denied
all the averments. They however admit that they repudiated
the claim. In their additional pleadings they state that the
appellant has not explained how and why he required a hip
replacement, hence his claim is suspicious and was
repudiated. They further state that he must have had the
disease prior to taking the policy and took the policy in
connivance with the agent. As per their investigation he was
suffering from the ailment prior to taking the policy and
suppressed the fact.
: 3 :
4.
The District Forum dismissed the complaint on the
ground that the case is too complicated and requires
voluminous evidence, hence it should be decided by a civil
court.
5.
We have heard the learned counsel for the
respondent. None was present for the appellant, who was
absent on the last date of hearing also.
6.
A perusal of the documents shows that the ground
taken by the insurance company for repudiating the claim,
vide their repudiation letter dated 17.7.08, is that ‘such
changes of arthritis cannot develop over 7 month period and
is pre-existing, hence as per policy condition clause 6B the
claim is inadmissible and not payable’.
7.
In the claim form the appellant has mentioned a
‘trivial fall’ in the bathroom. The medical certificate filled by
the attending physician clearly states that the insured had a
complaint of ‘post traumatic Avascular neurosis (Rt) Hip’ and
that it is not a complication of a pre-existing disease. The X-
ray report shows that the findings were suggestive of ‘stage
IV Avascular necrosis of femoral head right Hip with Arthritis’
: 4 :
8.
All these documents go to show that the appellant
was suffering from Avascular neurosis. It was not a pre-
existing disease. There is no mention in any medical paper
of the disease having progressed slowly over the years.
9.
Learned counsel for the respondents vehemently
argued
that
the
statements
of
the
appellant
are
contradictory. She argued that in his claim form he has
stated that he had a fall in the bathroom after which he
developed the problem, whereas in the complaint he says
that he was sick and developed backache. The argument is
without merit. In the claim form and in all the documents
submitted to the Insurance Company the appellant has
mentioned that he had a minor fall after which the problem
started. There was no difference in th
