State Consumer Disputes Redressal Commission
The New India Assurance Company Limited vs H.M. Kapoor And Another on 25 September, 2012
STATE CONSUMER DISPUTES REDRESSAL COMMISSION UTTARAKHAND
DEHRADUN
FIRST APPEAL NO. 179 / 2010
The New India Assurance Company Limited
through Divisional Manager
Divisional Office, Astley Hall
Dehradun
......Appellant / Opposite Party No. 1
Versus
1. Sh. H.M. Kapoor S/o late Sh. Mulkraj Kapoor
R/o 642, Sainik Colony, Roorkee
District Haridwar
......Respondent No. 1 / Complainant
2. Universal Medi-Aid Services Private Limited
Corporate Office at 1104, Akashdeep
26A, Barakhamba Road
New Delhi through its Authorised Signatory
......Respondent No. 2 / Opposite Party No. 2
Smt. Anjali Gusain, Learned Counsel for the Appellant
Sh. Sudhir Vashishtha, Learned Counsel for Respondent No. 1
None for Respondent No. 2
Coram: Hon'ble Mr. Justice B.C. Kandpal, President
Mr. C.C. Pant, Member
Mrs. Kusum Lata Sharma, Member
Dated: 25/09/2012
ORDER
(Per: Justice B.C. Kandpal, President):
This is insurer's appeal under Section 15 of the Consumer Protection Act, 1986 against the order dated 18.05.2010 passed by the District Forum, Haridwar in consumer complaint No. 60 of 2009. By the order impugned, the District Forum has allowed the consumer complaint and directed the opposite parties to pay the insured amount to the complainant and also to pay sum of Rs. 5,000/- towards damages.2
2. Briefly stated, the facts of the case as mentioned in the consumer complaint, are that the complainant had purchased a Hospitalisation and Domiciliary Hospitalisation Benefit Policy (Mediclaim Policy) from the opposite party No. 1 - The New India Assurance Company Limited (appellant before this Commission) for himself, his wife and son for assured sum of Rs. 2,00,000/- each. The policy was valid for the period from 03.01.2008 to 02.01.2009. Prior to the said policy, the complainant had also previously purchased the same policy in the last year, which was valid from 03.01.2007 to 02.01.2008. In the year 2008, the complainant suffered from heart ailment and on 18.09.2008, he was admitted in Indraprastha Apollo Hospital, New Delhi, where his angiography was done on 22.09.2008. The complainant was discharged from the hospital on 25.09.2008. The complainant informed the insurance company about his treatment. The insurance company asked the complainant to submit the claim form along with original bills and treatment papers. On 11.11.2008, the opposite party No. 2 asked for certain papers from the complainant. The complainant sent the papers as desired by the opposite party No. 2. As per the policy, the complainant was not to pay the expenses incurred on his treatment and the expenses were to be paid by the insurance company to the concerned hospital, but there was no tie-up between the insurance company and Indraprastha Apollo Hospital, New Delhi and, as such, the facility of cashless was not provided by the said hospital to the complainant. The complainant asked for settlement of his claim, which was repudiated by the opposite party No. 2 on the ground that the complainant had been suffering from the treated disease for the last 15-20 years and hence the claim is not payable. Alleging deficiency in service on the part of the opposite parties, the complainant filed a consumer complaint before the District Forum, Haridwar.
33. The insurance company filed written statement before the District Forum and pleaded that the liability to settle the claim is that of the opposite party No. 2 and it was merely an agent of the opposite party No. 2. The documents submitted by the complainant, were remitted to the opposite party No. 2 and it was further pleaded that the liability, if any, is that of the opposite party No. 2.
4. The opposite party No. 2 - respondent No. 2 also filed written statement before the District Forum and pleaded that as per the discharge summary of the complainant, he had been suffering from the disease treated for the last 15-20 years and hence the claim is not payable.
5. The District Forum, on an appreciation of the material on record, allowed the consumer complaint vide impugned order dated 18.05.2010 in the above terms. Aggrieved by the said order, the insurance company has filed this appeal.
6. None appeared on behalf of respondent No. 2. We have heard the learned counsel for the appellant and respondent No. 1 - complainant and perused the record.
7. Learned counsel for the appellant - insurance company submitted that the insurance company was merely an agent of the respondent No. 2 - Universal Medi-Aid Services Private Limited and the claim submitted by the complainant was forwarded by the insurance company to the said company and the claim was also repudiated by it and hence the liability, if any, to pay any amount to the complainant is that of the respondent No. 2 and the District Forum has erred in fastening the liability upon the insurance company.
48. We do not find any force in the above submission made by the learned counsel for the appellant. The reason being that the policy was issued by the appellant - The New India Assurance Company Limited. It appears that the appellant has appointed Universal Medi-Aid Services Private Limited in the matter to investigate the claim and submit the report on the status of the claim. It is true that the claim repudiation letter has been issued by Universal Medi-Aid Services Private Limited to the complainant, but the copy of the same was also forwarded to the appellant - insurance company. However, whatever the case may be, that is an internal matter of the insurance company with the said agency and the complainant has got no concern with the same. The complainant has purchased the mediclaim policy for himself, his wife and son from the appellant and he has lodged the claim with the appellant. If the appellant has appointed any of its agency to investigate the claim and the said agency has observed that the claim is not payable and has repudiated the same and issued the repudiation letter to the complainant, with a copy to the insurance company, it can not be said that the insurance company has no role in the matter.
9. So far as the repudiation of the claim is concerned, we do not find any justification for repudiation of the claim. The claim has been repudiated on the ground that the complainant had been suffering from the disease treated for the last 15-20 years. In the claim repudiation letter dated 10.01.2009 (Paper Nos. 50 to 51), it has been stated that the team of doctors has opined that the claim is not admissible. No such opinion has been placed on record. The insurance company has also not produced any evidence to show that the complainant was suffering from the said disease at the time of taking the mediclaim policy and he deliberately suppressed the same or that he was in the knowledge that he is suffering from any such 5 ailment and knowingly suppressed the same. It is also important to mention here that the policy in question was a renewed policy and prior to the said policy, the complainant had also previously purchased the same policy in the last year valid from 03.01.2007 to 02.01.2008. No plausible / cogent evidence has been adduced by the insurance company that the complainant was suffering from the disease treated upon at the time of taking the policy and he knowingly suppressed the same. Therefore, the repudiation of the claim on the ground of pre-existing disease and concealment of any fact, was not justified and the District Forum has rightly held that there has been deficiency in service on the part of the opposite parties by repudiating the claim of the complainant.
10. So far as the quantum is concerned, the insurance company has neither challenged the quantum awarded by the District Forum, nor has filed any evidence to show that the quantum of compensation awarded by the District Forum is on the higher side. The insurance company has also neither pleaded in the written statement or the appeal, nor has filed any documentary evidence to show that the claim made by the complainant to the extent of sum assured under the policy is excessive and that the expenditure to that extent, was not incurred by him in his treatment. The damages of Rs. 5,000/- awarded by the District Forum, are also justified and can not be said to be on the higher side.
11. For the reasons aforesaid, the appeal lacks merit and is liable to be dismissed.
12. Appeal is dismissed. No order as to costs.
(SMT. KUSUM LATA SHARMA) (C.C. PANT) (JUSTICE B.C. KANDPAL) K