State Consumer Disputes Redressal Commission
New India Assurance Co. Ltd. vs Jeevan Lal Verma on 4 April, 2019
STATE CONSUMER DISPUTES REDRESSAL COMMISSION UTTARAKHAND,
DEHRADUN
FIRST APPEAL NO. 161 / 2012
The New India Assurance Co. Ltd.
Branch Office: L.R. Shah Building, Mahatma Gandhi Marg, Almora
Through Regional Office
The New India Assurance Co. Ltd.
Gulfam House, 8/6-7, Astley Hall, Dehradun
.......Appellant / Opposite Party No. 1
Versus
1. Sh. Jeevan Lal Verma S/o Late Sh. G.L. Verma
R/o Savitri Cottage, Khajan Chand Mansion, Almora
.......Respondent No. 1 / Complainant
2. Universal Medi-Aid Services Pvt. Ltd.
1104, Akash Deep, 26A, Barakhamba Road, New Delhi
.......Respondent No. 2 / Opposite Party No. 2
Sh. M.K. Kohli, Learned Counsel for the Appellant
Sh. Vivek Painuli, Learned Counsel for Respondent No. 1
None for Respondent No. 2
Coram: Mr. Balveer Prasad, H.J.S., Member
Mrs. Veena Sharma, Member
Dated: 04/04/2019
ORDER
(Per: Mr. Balveer Prasad, Judicial Member):
This appeal has been preferred against the order dated 25.09.2012 passed by the District Consumer Disputes Redressal Forum, Almora (herein-after to be referred as 'The District Forum') in consumer-complaint No. 04 of 2009: Jeevan Lal Verma vs. The New India Assurance Co. Ltd., whereby the consumer complaint was allowed and the opposite parties were ordered to pay Rs.50,692/-2
alongwith simple interest @ 6% per annum, from the date of institution of the complaint till payment.
2. Briefly stated, the facts relevant for the disposal of the appeal are that the complainant - Sh. Jeevan Lal Verma preferred to file the complaint with the averments that he is the permanent resident of Almora and has got a policy of Hospitalization & Domiciliary Hospitalization Benefit policy, bearing No. 420902/34/07/20/00000010 which is continued since 2002. The complainant always paid the amount of premium regularly. The period of the above policy was from 30.07.2007 to midnight of 29.07.2008. By way of mediclaim policy, the complainant, his wife Smt. Shandhya Verma and his two sons: Aman & Nishant were covered for the benefit of the said policy. The sum assured was Rs. One Lac each. As per version narrated in the complaint, Master Aman Verma - the son of the complainant, had some eye problems and as such, he consulted Dr. M.S. Sachdeva, Centre for Sight Hospital, New Delhi. The complainant has further alleged that as per the terms and conditions of the policy, he was entitled to cashless benefit, but the same was not provided to him at the said hospital. It was also stated that he spent a sum of Rs.50,692/- in the operation / treatment of his son and submitted the claim with the appellant, which was repudiated by the said insurance company.
3. The consumer complaint was contested by the appellant and it was pleaded that the insured was suffering from pre-existing disease and the same was suppressed by the respondent No. 1 at the time of obtaining the policy and as such, the claim was not payable and was rightly repudiated. It was also urged that Dr. Arun Gupta in his report dated 16.05.2008 has clearly stated that Master Aman Verma had developmental Cataract in both his eyes and developmental Cataract 3 is congenital external disease which falls under permanent exclusion of the policy.
4. On careful consideration of the matter, the District Forum allowed the consumer - complaint in the terms depicted as above. Feeling aggrieved, The New India Assurance Co. Ltd. filed this appeal.
5. Learned counsel for the appellant submitted that the complainant's son was suffering from pre-existing disease at the time of obtaining the policy, it was not justified on the part of the District Forum to allow the consumer - complaint. Also emphasised that the order impugned is against law, facts & merits of the case.
6. Per contra, it has been argued on behalf of the respondent No. 1 that the District Forum has rightly appreciated the evidence & passed a just verdict.
7. We have given thoughtful consideration to the arguments advanced before us and examined the entire material on record.
8. In order to appreciate the issue involved, we think it proper to have a glance on the factual matrix of the case. The record spells out that 'the exclusion clause 4.8 of the policy specifies that the company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in respect of congenital external disease or defects or anomalies...' The company observed that the presenting condition of developmental Cataract is congenital external disease, falling under permanent exclusion clause, treating the same as pre-existing.
49. It is significant to place on record that the parties are maintaining relationship of mutual trust & confidence since 2002. The medi-claim policy of the family is running regularly year to year. Admittedly, the hospitalization took place during the subsistence of the policy, effective from 30.07.2007 to 29.07.2008.
10. Document (23A/10; District Forum's file) speaks that even after the repudiation of the claim, the complainant maintained continuity by taking policy from 30.07.2008 to 29.07.2009, wherein the pre-existing disease is recorded as 'No'. This document by itself cuts the root of the defence raised by the insurance company. Paper No. 29 A/12 & 13 (District Forum's file) is the report, dated 16.05.2008 issued by Dr. Arun Gupta, M.B.B.S., verifying the expenses amounting to Rs.50,692/- as 'Net Payable Amount' but holding the claim - status as 'Not Payable' on account of the Exclusion Clause, stated as above. Even after getting the report of Dr. Arun Gupta, the insurance company accepted the premium for the medi-claim policy as detailed above. In view of this, the principle of Estoppel operates against the appellant.
11. It transpires from record that the claim is based on truth and rated as genuine. The Law postulated by Hon'ble Apex Court is a good guide on the point, quoted as under:-
'Courts must take realistic view and compensation, if possible on the material on record, should not be denied on hyper-technical pleas.' (Dharmendra Goel vs. Oriental Insurance Co. Ltd.) III (2008) CPJ 63 (NC).
12. The District Forum carefully appreciated the evidence available on record, assigned cogent reasons and arrived at a just conclusion.
5On re-assessment of the matter, we find no ground for interference at all. Thus, we confirm the verdict passed by the District Forum.
13. As concluded above, the Appeal is dismissed. No order as to costs.
(MRS. VEENA SHARMA) (BALVEER PRASAD)