National Consumer Disputes Redressal
National Insurance Co. Ltd. vs Radhey Shyam Balwada & Anr. on 4 March, 2014
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI REVISION PETITION NO. 3258 OF 2013 (From order dated 29.05.2013 in First Appeal No. 185 of 2013 of the Rajasthan State Consumer Disputes Redressal Commission, Jaipur) National Insurance Company Ltd. Through its Authorized Signatory Regional Office at Jeevan Nidhi, Bhawani Singh Road, Ambedkar Circle, Jaipur Petitioner Versus 1. Radhey Shyam Balwada R/o Opp. Of Bhadada Bagh, Pratap Takiz Road, Bhilwara. 2. M/s Vipul Med Corp TPA Pvt. Ltd. 515, Udyog Vihar, Phase-5, Gurgaon, Haryana Respondents BEFORE: HONBLE MR. JUSTICE J.M.MALIK, PRESIDING MEMBER HONBLE DR. S.M. KANTIKAR, MEMBER For the Petitioner : Ms. Neerja Sachdeva, Advocate For the Respondent No.1 : Mr. H.D. Thanvi, Advocate For the Respondent No. 2 : Nemo PRONOUNCED ON 4th MARCH, 2014 ORDER
PER DR. S.M. KANTIKAR, MEMBER
1. The present Revision Petition has been filed by the Petitioner against the judgment of the State Consumer Disputes Redressal Commission, (hereinafter referred to as, State Commission) in FA/185/2013, whereby the Appeal of the Appellant was allowed. The Appeal was filed in the State Commission aggrieved by the order of the District Consumer Disputes Redressal Forum (in short, District Forum) in Complaint No. CC/120/2012.
2. The brief facts are that since the year 2003, the Complainant, Radhysham Baldawa took a Hospitalisation Benefit (a mediclaim) policy covering himself and his family members, for the period from 25.06.2011 to 24.06.2012. His mediclaim cover was for the sum of Rs.1,50,000/- and Rs.60,000/- as bonus, thus the total amount of the insurance policy was Rs.2,10,000/-. The policy was renewed, from time to time, since the year 2003. During the existence of the policy, the Complainant suffered abdominal pain during 25.07.2011 to 03.09.2011, and it was diagnosed that he had a stone in the gall bladder. After consultation at Hari Bhakti Surgical Hospital, Ahmedabad, the Complainant was operated upon at Sterling Hospital, Ahmedabad, on 01.09.2012, and he was discharged from the hospital, on 03.09.2011. The Complainant spent a sum of Rs.1,31,257/- on his treatment during the period. The Complainant submitted the claim form for the aforesaid amount, before the OP, but the OP made a payment of Rs.52,505/- only, as full and final payment, against the claim. Hence, a complaint before the District Forum was filed, for payment of balance amount to the Complainant. The District Forum allowed the complaint and directed the OP to pay a sum of Rs.78,752/- to the Complainant, within a period of one month.
3. Thereafter, being aggrieved by the said order of District Forum, the Petitioner herein, filed First Appeal No. 185 of 2013, before the Rajasthan State Commission at Jaipur.
4. The State Commission confirmed the findings of District Forum, holding that it is a fraud, on part of the insurance companies, when they repudiate or illegally deduct the claim amount, on technical and frivolous grounds, under the garb of exclusion clauses. The State Commission relied upon the judgment of the Honble Supreme Court in the case of United India Insurance Company Ltd. Vs. M.K.J. Corporation held that an insured is not bound by the exclusion clause of the policy, if the same is not explained to him. The State Commission dismissed the appeal on 29.05.2013.
5. Therefore, this revision petition has arisen against the order of State Commission.
6. We have heard the rival contentions advanced by counsel of the parties and perused the relevant documents, medical records, on file. It is an admitted fact that the Complainants Mediclaim policy was in existence since 26.6.2003, and was in force, during the period from 25.06.2011 to 25.06.2012, for a total cover of Rs.1,50,000/- plus Rs.60,000/-, as a bonus. It is also an admitted fact that the Complainant suffered a pain in his abdomen, on 25.07.2011, and he remained sick, till 03.09.2011.He was diagnosed to have gall stone and he was operated for removal of gall stones, on 01.09.2011, and was discharged from the hospital on 03.09.2011. It is also evident that the Complainant spent a total sum of Rs.1,37,257/-, on his treatment, but the Insurance Co. made a payment of Rs.52,505/- and repudiated the claim for the balance amount of Rs.78,752/-. The OP deducted a sum of Rs.78,752/- from the claim amount, under the garb of exclusion clause of the policy, which was never explained to the Complainant; and it appears to be just, a technical ground.
7. We have perused the policy conditions and exclusion clause. The condition at 3.1: i.e., Pre Hospitalization: Relevant Medical expenses incurred during the period, upto 30 days, prior to hospitalization/domiciliary on disease/illness/injury sustained, will be considered as part of claim mentioned, under item 1.0, above. It was an admitted fact that the complainant suffered gall stone illness from 25.07.2011 to 03.09.2011 and incurred total expenses of Rs.131257/- We are of considered view that OP was not justified in making payment of Rs.52,505/- only. Such act of OP appears to be an intentional and technical one, to harass the bonafide customer. Also, there is no evidence on record to show that condition No. 3.1 and the exclusion clause was explained to the Complainant-insured, at the time of submission of the proposal form by him. The customer avails the Mediclaim insurance policy, with the hope that medical treatment expenses will be reimbursed by the Insurer. Therefore, insurer (OP) also has duty to act in good faith, which obliges him to enter into the contract, without concealing the material fact like exclusion clause. We feel that the act of OP is unjust and unfair towards the complainant, who took the said policy, since 2003, and was renewing it from time to time, since then.
8. Accordingly, we do not find any flaw or disparity in the orders passed by both the fora below; hence this revision petition is dismissed. The OP is directed to comply with the impugned order, within 90 days, from the receipt of this order, otherwise, it will carry further interest @ 9% p.a. on entire amount, till its realisation. Parties are directed to bear their own costs.
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(J. M. MALIK, J.) PRESIDING MEMBER ...
(S. M. KANTIKAR) MEMBER Mss/11