State Consumer Disputes Redressal Commission
The New India Assurance Company Limited vs Satinder Saini on 29 April, 2001
2nd Bench
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB
SCO NO.3009-12, SECTOR 22-D, CHANDIGARH.
First Appeal No.855 of 2008.
Date of Institution: 12.08.2008.
Date of Decision: 29.04.2011.
The New India Assurance Company Limited, Nangal Chowk, Ropar, through
its Branch Manager, through its Manager (Legal), New India Assurance
Company Limited, Regional Office, SCO No.36-37, Sector 17-A, Chandigarh.
.....Appellant.
Versus
1. Satinder Saini, aged about 39 years, son of Sh. Rattan Saini, R/o 17,
Guru Teg Bahadur Nagar, Ropar, District Ropar, Punjab.
....Respondent
2. Ex. Meditek Solutions Limited, Corporate Office 45, Nathupur Road,
DLF, Phase-III, Gurgaon-122002 (Haryana).
...Performa Respondent.
First Appeal against the order dated
14.05.2008 of the District Consumer
Disputes Redressal Forum, Ropar.
Before:-
Shri Inderjit Kaushik, Presiding Member.
Shri Piare Lal Garg, Member.
Present:-
For the appellant : Sh. Rajneesh Malhotra, Advocate. For respondent no.1 : Sh. Naresh Kaushal, Advocate with Sh. Satinder Saini, in person.
For respondent no.2 : Service dispensed with. INDERJIT KAUSHIK, PRESIDING MEMBER:-
The New India Assurance Company Limited appellant (In short "the appellant") has filed this appeal against the order dated 14.05.2008 passed by the learned District Consumer Disputes Redressal Forum, Ropar (in short "the District Forum").
2. Facts in brief are that Sh. Satinder Saini, respondent no.1/complainant (in short, "respondent no.1") filed a complaint under section 12 of the Consumer Protection Act, 1986 (in short, "the Act") against the appellant and respondent no.2, on the allegations that respondent no.1 took First Appeal No.855 of 2008 2 mediclaim insurance policy from the respondent no.2, who is agent of the appellant, for the period 14.11.2006 to 13.11.2006 vide policy no.352301/48/05/20/70050022 for himself and his wife Smt. Veena Saini and respondent no.2 issued the card no.NA-INDN-1837216 to respondent no.1. Policy expired on 13.11.2006 and before that respondent no.1 paid the premium and the policy was renewed by the appellant vide policy no. 352301/48/06/20/70000032 for a period of one year from 14.11.2006.
3. The respondent no.1 suddenly fell ill and was hospitalized in Fortis Hospital, Mohali and remained admitted in the hospital from 15.10.2007 to 21.10.2007 and submitted his claim for reimbursement of the expenses incurred by respondent no.1 on his treatment along with documents, but the appellant had not cleared the claim and ultimately, repudiated the same vide letter dated 15.01.2008, taking recourse to Exclusion Clause 4.8 of the policy. The appellant repudiated the claim without application of mind and just to harass respondent no.1 as he never takes liquor and before issuing the policy, respondent no.1 was thoroughly got checked and there is deficiency in service on the part of appellant and respondent no.1 and prayed that the appellant and respondent no.1 be directed to pay claim amount along with interest @ 12% p.a., Rs.50,000/- as compensation and Rs.30,000/- as litigation expenses.
4. In the reply filed on behalf of the appellant, preliminary objections were taken that respondent no.1 has not come to the Forum with clean hands and concealed his previous illness, claim regarding which was earlier repudiated vide letter dated 03.03.2007. Respondent no.1 was suffering from Pancreatitis on account of consumption of alcohol and earlier also, he lodged the claim and the same was repudiated. Complaint is false and there is no deficiency in service on the part of the appellant. On merits, it was admitted that respondent no.1 has taken mediclaim insurance policy from the appellant, but respondent no.2 is not the agent of appellant and is the First Appeal No.855 of 2008 3 third party administrator. It was also admitted that the mediclaim policy was valid w.e.f. 14.11.2005 to 13.11.2006, covering respondent no.1 as well as his wife, but it was clarified that the risk is covered as per the terms and conditions of the policy and the cards were issued to him by respondent no.2. The policy was renewed w.e.f. 14.11.2006 to 13.11.2007. Respondent no.1 was hospitalized as per the claim form and remained admitted w.e.f. 15.10.2007 to 21.10.2007. Respondent no.1 has earlier lodged a claim with the appellant for the period of hospitalization w.e.f. 06.01.2007 to 07.01.2007 and that claim was duly looked into and was for the disease and treatment of Pancreatitis which was due to consumption of alcohol and the claim was repudiated as per Clause-4.8 of the policy. Claim lodged by respondent no.1 was repudiated vide letter dated 15.01.2008 as per terms and conditions of the policy. Denying all other allegations contained in the complaint, it was prayed that the complaint may be dismissed.
5. Respondent no.2 did not contest the complaint before the District Forum and was proceeded against exparte.
6. Contesting parties led evidence in support of their respective contentions by way of affidavits and documents.
7. After going through the documents and material placed on file and after hearing the learned counsel for the parties, the learned District Forum observed that simply because earlier claim was rejected on account of Pancreatitis, the insurer cannot be allowed to reject the present claim also. Simple production of copies of previous case history does not amount to production of tangible evidence in that context and the repudiation amounts to deficiency in service, and allowed the complaint, directing the appellant to pay the claim amount along with interest @ 12% p.a. from the date of repudiation till the date of payment and Rs.4000/- as compensation.
8. Aggrieved by the impugned order dated 14.05.2008, the appellant has come up in appeal.
First Appeal No.855 of 2008 4
9. We have gone through the pleadings of the parties, perused the record of the learned District Forum and have heard the arguments advanced by the learned counsel for the appellant and respondent no.1.
10. Respondent no.2 is performa respondent and service of respondent no.2 was dispensed with vide order dated 21.11.2008 of this Commission.
11. It was contended by the learned counsel for the appellant that respondent no.1 was admitted in Fortis Hospital and he was suffering from Pancreatitis due to consumption of alcohol and as per Clause-4.8 of the policy, the claim was repudiated. Earlier also, respondent no.1 was admitted for the same disease i.e. Pancreatitis and the said disease relates to alcohol abuse and the order of the District Forum is not sustainable.
12. On behalf of the respondent no.1, it was contended that that there is no evidence that the disease of Pancreatitis was due to use of alcohol. Respondent no.1 was admitted in Fortis Hospital due to pain in abdomen and the appellant has not examined any doctor or the person, who gave history on the basis of discharge summary and the copies of the record placed on file are not sufficient to prove that the disease of Pancreatitis was due to alcohol abuse and without there being any evidence, the appellant cannot take recourse to Clause-4.8 of the policy. There is no illegality in the impugned order and the appeal may be dismissed.
13. We have considered the submissions made by the learned counsel for the appellant and respondent no.1.
14. The appellant has placed on file affidavit of Sh. Surinder Singh, Divisional Manager Ex.RA, affidavit of Sh. Anil Dogra, AAO Ex.RB and repudiation letter Ex.R2 and the appellant has taken recourse to the Exclusion Clause 4.8 of the policy Ex.R1 and much stress was laid that the disease of Pancreatitis was due to the use of alcohol. The appellant has also placed on record the medical record of the Fortis Hospital. Respondent no.1 First Appeal No.855 of 2008 5 has also relied upon the same record. Respondent no.1 has also relied upon the repudiation letter Ex.C2 and in the said repudiation letter also, the claim has been repudiated on the basis of Exclusion Clause 4.8. The policy renewal letter is Ex.C3 and the record of the Fortis Hospital relied upon by respondent no.1/complainant is Ex.C5 to Ex.C9 and the discharge summary (which is part of Ex.C9) shows the diagnosis as 'acute Pancreatitis' and in the past history, it has been mentioned as 'not significant' and the illness was 'pain abdomen for around 12 hours' and on physical examination, nothing abnormal was detected. Ex.C5 to Ex.C8 also suggest that the abdomen pain was due to fatty liver and Hypoechoic and Bulky (body) Pancreatitis and nowhere, it is mentioned that the disease Pancreatitis was due to the use of alcohol. The appellant has also placed on the file photostat copies of the record or Fortis Hospital including the discharge summary, but neither the discharge summary nor any doctor of the hospital or his affidavit is not on record to suggest that the disease of Pancreatitis was due to the use of alcohol and as such, the repudiation of the claim of respondent no.1 by the appellant was not justified in any manner and the appellant has failed to bring on record any evidence to prove so. No doctor of Fortis Hospital or any other expert has been examined to prove that the disease of Pancreatitis was due to use of alcohol and the Exclusion Clause-4.8 of the policy Ex.R1 was applicable. The District Forum has also rightly observed that there is no evidence to prove so. The order of the District Forum is legal and valid and there is no ground to interfere in the same.
15. In view of above discussion, the appeal being without any merit is dismissed and the impugned order dated 14.05.2008 passed by the District Forum under appeal, is affirmed and upheld. No order as to costs.
16. The appellant had deposited an amount of Rs.25,000/- with this Commission at the time of filing of the appeal and another sum of Rs.92,941/- vide receipt no.16 dated 25.09.2008 in compliance of order dated 27.08.2008 First Appeal No.855 of 2008 6 passed by this Commission. Both these amounts with interest accrued thereon, if any, be remitted by the registry to respondent no.1/complainant by way of a crossed cheque/demand draft after the expiry of 45 days under intimation to the learned District Forum and to the appellant.
17. The arguments in this appeal were heard on 28.04.2011 and the order was reserved. Now the order be communicated to the parties.
18. The appeal could not be decided within the stipulated timeframe due to heavy pendency of court cases.
(Inderjit Kaushik) Presiding Member (Piare Lal Garg) Member April 29, 2011.
(Gurmeet Singh)