State Consumer Disputes Redressal Commission
Reliance General Insurance vs The High Court Lawyers, on 11 November, 2009
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
STATE CONSUMER DISPUTES
REDRESSAL COMMISSION,
UNION TERRITORY,
CHANDIGARH.
Appeal case No.237/2009
Date of institution:1.5.2009
Date of decision :11.11.2009
Reliance
General Insurance, Anil Dhirubhai Ambani Group, First floor, SCO No.147-148,
Sector-9, Madhya Marg, Chandigarh through its Assistant Manager Legal(claims)
.Appellant
V E R S U S
The High court Lawyers, Public Charitable Trust (regd.) Administrative
block, high court premises at Chandigarh through Ajaib Singh Tung,advocate son
of Sh.Sunder Singh.
.Respondent
Appeal U/s 15 of Consumer Protection Act,1986 against
order dated 1.4.2009 passed by
Consumer Disputes
Redressal Forum-II,
U.T.Chandigarh.
Argued
by: Sh.Mrigank Sharma,advocate for the appellant.
Sh. Gaurav Bhardwaj,
advocate for respondent.
BEFORE : Honble
Mr.Justice Pritam Pal, President
Maj.Gen.S.P.Kapoor
(retd), Member
Mrs. Neena Sandhu,Member
JUDGMENT
11.11.2009 Justice Pritam Pal, President
1. This appeal by opposite party is directed against the order dated 1.4.2009 passed by District Consumer Forum-II, U.T.Chandigarh whereby complaint filed by the High Court Lawyers, Public Charitable Trust through Ajaib Sing Tung, advocate for the mediclaim of his wife was allowed in the following terms ;
Keeping in view of this, it is our considered opinion that the present complaint must succeed in favour of the complainant and against the OP and we order accordingly. We pass the following order and the OP is directed to make the following payments to the complainant ;
i) to pay a sum of Rs.1.00 lac i.e. the insured sum alongwith interest @ 9% per annum on account of the mediclaim from the date of repudiation of the claim i.e. 20.11.2007 till the date of realization.
ii) to pay Rs.5000/- as cost of litigation.
This order be complied with by OP within a period of six weeks of the receipt of its certified copy by them, failing which the OP shall pay a sum of Rs.1.00 lac alongwith interest @ 15% per annum from 20.11.2007 till realization in addition to cost of litigation.
2. The facts culminating to the commencement of this appeal may be recapitulated thus ;
The complainant is a Charitable Trust duly registered with its office at Administrative Block, High Court Premises at Chandigarh and the complainant authorized Mr. Ajaib Singh Tung to file the claim against the OP. There were 1682 advocate members including Sh. Ajaib Singh Tung who were insured with the OP insurance company and the complainant had paid a premium of Rs.36,56,301/- to the OP insurance company for taking Group insurance Mediclaim policy. The policy bearing No.2004072811000001 was issued by OP which was valid from 16.8.2007 upto midnight of 15.08.2008 . According to the said policy of Insurance, all 1682 advocate members including Ajaib Singh Tung, Advocate and his spouse and two unmarried dependent children were insured for mediclaim to the tune of Rs.1.00 lacs each family member. It was alleged that Mrs. Ranjit Kaur wife of Sh. Ajaib Singh Tung, Advocate, covered under the Insurance Policy did not have any pre-existing disease including Cardiac Problem. However, as she complained of stomach pain , her husband took her to Liberty Hospital Mohali, where she was admitted on September 07,2007 and she was diagnosed to be having a stone in the gall bladder. According to the Ultra Sound Report, the Gall Bladder Phase was fully distended, the lumen was big 1.20 cm mobile calculus with biliary sludge and small calculi seen and common duct was dilated 12 mm in almost entire length and she was rushed to Fortis Hospital, Mohali on 08.09.2007 where she was found to be suffering from acute coronary syndrome, acute pulmonary edema and acute ATN and stent to LAD. She remained on ventilator for 5/6 days and it was only on 14.09.2007 that coronary Angiogram was done which revealed double Vessel Disease and thus she underwent PTCA on the same day and had spent more than Rs.5,38,000/- for the treatment on his wife in the Fortis Hospital, Mohali. The complainant filed the claim of rupees one lac and submitted the necessary documents but OP instead of making the payment of rupees one lac to the insured member, repudiated the claim under Policy exclusion clause No.4.1. Complainant then approached OP so many times to settle his claim but of no avail. Alleging deficiency in service on the part of OP, complainant filed complaint before the District Consumer Forum seeking directions to OP to pay a sum of Rs.1.00 lac alongwith interest @12% besides compensation and litigation costs.
3. On the other hand, the stand of OP before the District Forum was that it was a case of pre-existing disease as the insured was admitted in the Fortis Hospital on 08.09.2007 and was having history of pain in Abdomen since the last six months and ultimately it was found to be a case of double vessel disease and she underwent PTCA on the same day. It was pleaded by OP that the double vessel disease does not develop within a span of one or two months but it takes a longer period to develop. Hence, it was clear case of a pre-existing disease and accordingly, the claim was repudiated under Clause 4.1. It was further pleaded that the claim was also not found payable under Clause 4.2 as per this clause the claim was not payable if such a disease was contracted by the insured person during the first 30 days from the commencement date of the policy. The policy started from 16.08.2007 and the date of admission in the hospital was 08.09.2007,therefore, it could safely be said that the insured was hospitalized within 30 days of the policy and as such the claim was rightly repudiated under Clause 4.2 and there was no deficiency in service and a prayer was made for dismissal of the complaint .
4. The learned District Consumer Forum after going through the file and hearing the learned counsel for parties, allowed the complaint as indicated in the opening part of this judgment. This is how feeling aggrieved against the said order, opposite party has come up in this appeal.
5. We have heard learned counsel for the parties and also gone through the file carefully. The only noticeable point raised on behalf of appellant/Opposite party (hereinafter to be referred as OP) is that in view of the terms and conditions laid under exclusion clause 4.1 respondent/complainant (hereinafter referred to as complainant) is not entitled to any compensation as she was suffering from pre-existing disease, so, claim was rightly repudiated by OP. This contention has been repelled by the learned counsel for complainant and at the same time he made reference to the certificate of treating doctor placed and proved on the file of District Forum at page-25.
6. We have given our thoughtful consideration to the aforesaid sole point raised on behalf of appellant and find the same to be devoid of any merit. Before we proceed further, let us reproduce the certificate issued by Dr. Rakesh K.Jaswal, who is highly qualified having the degrees of MD(Medicine) D.M.(Cardiology and also an additional Director Interventional cardiology working in the Fortis Hospital. He was the doctor who had treated Mrs. Ranjit Kaur wife of Sh.Ajaib Singh Tung,advocate, complainant in this case. The certificate dated 14.9.2007 reads as under ;
This is to certify that Mrs. Ranjit Kaur vide UHID 138827 wife of S.Ajaib Singh Tung, advocate member Punjab and Haryana High Court Association, Chandigarh was admitted on 8th September,2007 in Fortis Hospital, Super Speciality in heart, Mohali. She had acute coronary syndrome. Acute Pulmonary edema and acute ATN. She had to be immediately put on ventilator and required an urgent life saving PTCA+stent to LAD. It is further clarified and certified that according to our medical record, patient had no pre-existing cardiac disease before this admission.
7. A perusal of the above certificate based on medical record of the patient goes a longway to show that Mrs.Ranjit Kaur had no pre-existing cardiac disease before her admission in the said hospital on 8.9.2007. On the other hand, OP has failed to produce any cogent and convincing medical evidence to rebut the aforesaid report of the doctor of Fortis hospital where the patient was admitted and treated in respect of her disease. Thus, we have no hesitation to hold that infact the wife of complainant Sh.Ajaib Singh Tung who is member of the High court Bar Association was not having any pre-existing disease at the time of taking insurance policy and as such the exclusion clauses 4.1 & 4.2 of the conditions attached to the policy were not attracted to her case.
8. In the result, we find no force in the appeal and consequently the same is dismissed with cost which is quantified at Rs.5000/-
Certified copies of this order be communicated to the parties, free of charge. The file be consigned to records.
Sd/-
Announced ( Justice Pritam Pal)(Retd.) 11th Nov.,2009 President Sd/-
( Maj.Gen.S.P.Kapoor)Retd Member Sd/-
(Mrs.Neena Sandhu) Member *Js