State Consumer Disputes Redressal Commission
Oic And Another vs Dr. Anil Ku. Agrawal on 9 May, 2018
Daily Order M. P. STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PLOT NO.76, ARERA HILLS, BHOPAL FIRST APPEAL NO. 614 OF 2009 (Arising out of order dated 24.12.2008 passed in C.C.No.316/2008 by District Forum, Gwalior) 1. THE ORIENTAL INSRUANCE CO.LTD. THROUGH DIVISIONAL MANAGER, DIVISIONAL OFFICE, PURI SADAN, CIRCUIT HOUSE CHOWK, SATNA (M.P.) 2. PARA MOUNT HEALTH SERVICE CENTRE PVT.LTD. THROUGH MANAGER, 205, SECOND FLOOR, EVING SHALIMAR CORPORATION, CENTER, SOUTH TUKOGANJ, INDORE (M.P) ... APPELLANTS. Versus DR. ANIL KUMAR AGARWAL, S/O SHRI S.C.AGRAWAL, VETERNARY DOCTOR, R/O F-24, M-BLOCK, GOVT.QUARTERS, THATIPUR, GWALIOR (M.P.) ... RESPONDENT. BEFORE : HON'BLE SHRI S. D. AGARWAL : PRESIDING MEMBER
HON'BLE DR (MRS) MONIKA MALIK : MEMBER COUNSEL FOR PARTIES : Shri Ravindra Tiwari, learned counsel for the appellant. Ms. Sangeeta Moharir, learned counsel for respondent. O R D E R (Passed On 09.05.2018)
The following order of the Commission was delivered by Shri S. D. Agarwal, Presiding Member:
This appeal has been preferred by the opposite party/appellant (for short 'appellant') under Section 15 of the Consumer Protection Act, 1986 against the order dated 24.12.2008 passed by the District Consumer Disputes Redressal Forum, Gwalior in C.C.No.316/2008 whereby the complaint filed by the complainant/respondent has been allowed and the opposite party/appellant were directed to settle the claim of the complainant within a month and to pay the admissible amount. Cost of Rs.1000/- has also been awarded to the complainant.
2. Briefly stated, the facts of the case as narrated by the complainant/respondent are that he obtained a mediclaim policy no.153400 on 28.12.2005 from opposite party no.1/appellant no.1, by depositing premium amount Rs.2197/-. According to the policy, the opposite party no.2/appellant no.2 was liable for -2- settling the cashless medical facility and claim settlement. According to the complainant, the policy was renewed before 28.12.2006 and its maturity date was 27.12.2007. In June-2007, the complainant fell ill because of pain in abdomen and on medical checkup he was diagnosed as Incisional Hernia. From 11.12.2007 to 16.12.2007 he remained in Sir Gangaram Hospital, New Delhi for operation and treatment. During his treatment he deposited Rs.83,802/- in the Hospital. On being submitted necessary documents for settlement of claim before the appellants, the same was repudiated on the ground of exclusion clause 4.1 of the policy. The complainant therefore filed a complaint before the District Forum alleging deficiency in service and unfair trade practice on the part of the opposite parties.
3. The appellants/opposite parties before the District Forum filed their written statement rebutting the charges and stated that the complainant was a patient of incisional hernia which he was suffering from before taking the policy. The complainant underwent operation for two times but the ailment was not cured despite two operations. Therefore, third time again he took treatment in Sir Gangaram Hospital, New Delhi. As per appellants, insurance cover was not applicable for pre-existing disease, the complainant/respondent was suffering from.
4. The Forum after appreciation of evidence adduced by both parties inferred that earlier two operations in the year 2004 & 2005 were for different disease and the appellants failed to adduce any evidence that complainant was earlier treated for Incisional Hernia. The Forum also found that the proposal form 'Exhibit R-3' clearly indicates that complainant furnished information regarding his treatment in Sir Gangaram Hospital, New Delhi earlier and no fact has been concealed by him. After examining the proposal form, the appellants issued policy to their satisfaction. Therefore, the Forum allowed the complaint and ordered the opposite party to settle the claim of the complainant and to pay the admissible amount.
5. The instant appeal has been filed against the impugned order stating that the Forum has not appreciated the evidence, Exhibit C-8 & C-9, filed by the complainant which indicated that complainant was suffering from incisional hernia before obtaining the policy. It is also submitted in the appeal, that complainant deliberately concealed the fact of earlier treatment of pre-existing disease in Sir Gangaram Hospital, New Delhi.
6. Heard learned counsels for parties. Perused the record.
-3-7. Learned counsel for appellant insurance company vehemently argued that the treatment taken by the respondent at Sir Gangaram Hospital, New Delhi were for Incisional Hernia and the treatment taken third time was in sequence of earlier treatment, therefore, according to exclusion clause 4.1. of the policy, the complainant was not entitled to get any claim under the mediclaim policy.
8. Learned counsel for respondent argued that the earlier treatment taken by the respondent at Sir Gangaram Hospital was for the period 20.11.2004 to 13.12.2004 and was for 'Peritonitis with Septic Shock', thereafter from 02.02.2005 to 11.02.2005 was for 'Enteric Perforation Post-Operative with Ileostomy' which is different from Incisional Hernia. Moreover, the complainant while obtaining the policy furnished entire facts in his proposal form, therefore, his integrity cannot be doubted while taking the policy.
9. On perusal of record, we see that the complainant remained hospitalized in Sir Gangram Hospital for the period for the period 20.11.2004 to 13.12.2004 for treatment 'Peritonitis with Septic Shock' thereafter from 02.02.2005 to 11.02.2005 for treatment of 'Enteric Perforation Post-Operative with Ileostomy', which is quite different from Incisional Hernia. The information regarding Peritonitis received from Internet is as follows:
Peritonitis is inflammation of the peritoneum, the thin layer of tissue covering the inside of your abdomen and most of its organs. The inflammation is usually the result of a fungal or bacterial infection. This can be caused by an abdominal injury, an underlying medical condition, or a treatment device, such as a dialysis catheter or feeding tube.
The following conditions can lead to peritonitis:
An abdominal wound or injury A ruptured appendix A stomach ulcer A perforated colon Diverticulitis Pancreatitis, or inflammation of the pancreas Cirrhosis of the liver or other types of liver disease.
10. The treatment taken by the complainant/respondent for the third time for the period 11.12.2007 to 16.12.2007 at Sir Gangaram Hospital for Incisional Hernia. The Forum has rightly inferred that the peritonitis and incisional hernia are quite different diseases and incisional hernia cannot be fall out of peritonitis. We agree with the -4- contention of learned counsel for respondent/complainant that the complainant honestly disclosed all information regarding his earlier treatment at Sir Gangaram Hospital, New Delhi, therefore, his integrity cannot be doubted. The policy was also given by the appellant insurance company after due consideration of proposal form wherein nothing has been mentioned regarding incisional hernia. This is for the first time in the year 2007 the complainant took treatment for incisional hernia. Therefore, the policy covered for the treatment of this disease and exclusion clause does not apply on the treatment of incisional hernia. We therefore infer that this appeal has no merit and the order of the District Forum being legal is upheld. The appeal is dismissed. The appellants are directed to settle the claim of the respondent and to pay him the admissible amount of his claim within a period of two months from the date of receipt of copy of this order. The appellants are also directed to pay interest @ 9% p.a. on the admissible amount from the date of filing of complaint till payment. If the appellants failed to settle the claim within a period of two months, the interest on the admissible amount will be paid @ 12% p.a.. The appellants shall also pay Rs.1000/- as costs of this appeal to the respondent.
(S. D. AGARWAL) (DR. MRS. MONIKA MALIK) PRESIDING MEMBER MEMBER