State Consumer Disputes Redressal Commission
The United India Insurance Co. Ltd vs Mr Romesh G Porwal & Anr on 4 December, 2013
BEFORE THE HON'BLE STATE CONSUMER DISPUTES REDRESSAL
BEFORE THE
HON'BLE STATE CONSUMER DISPUTES REDRESSAL
COMMISSION, MAHARASHTRA, MUMBAI
First Appeal
No. A/11/429
(Arisen out
of Order Dated 15/02/2011 in Case No. 522/2006 of District Pune)
THE UNITED INDIA INSURANCE CO. LTD.
MUMBAI REGIONAL OFFICE NO II
MAKER BHAVAN 3 RD FLOOR SIR V T MARG
MUMBAI 400020
...........Appellant(s)
Versus
1. MR ROMESH G PORWAL
R/AT
F-213/217 SECOND FLOOR PARMAR TRADE CENTER SADHU WASWANI CIRCLE
PUNE 411001
2. M/S FAMILY HEALTH PLAN LTD.
ADITYA JR TOWERS, 8-2-120/86/9A&B
3 RD & 4
TH FLOOR NO 2 BANJARA HILLS HYDERABAD.
OTHER ADD .KUKY VILLA 4 TH FLOOR BEHIND SYNDICATE
BANK KHAR WEST
MUMBAI 400052
...........Respondent(s)
BEFORE:
HON'ABLE MR. JUSTICE R.C.Chavan PRESIDENT
HON'ABLE MR. Dhanraj Khamatkar Member
PRESENT:
Mr.Amol More-Advocate proxy for Mr.Sanjay
Mhatre-Advocate for the appellant
Mr.T.S.Vidwans -Advocate for the respondent.
ORDER
Per Honble Mr.Justice R.C.Chavan, President This appeal is directed against the order passed by the District Consumer Disputes Redressal Forum, Pune allowing consumer complaint no.522/2006, whereby forum directed appellant/Insurance Company to pay a sum of `1,50,000/- with interest @ 9% p.a. and costs of `1,000/- to the complainant towards the claim made under the Mediclaim policy. Facts which are material for deciding this appeal are as under:-
Complainant had obtained a mediclaim policy from the appellant company which was valid for a period from 03/06/2004 to 02/06/2005. On 10/07/2004, he had some chest pain and, therefore, he had first consulted Dr.Agarwal and then Dr.Advani. Thereafter, on 12/07/2004, he underwent angioplasty at a cost of `2,27,422/-. He made a claim of this amount with the appellant-Insurance Company.
Insurance Company repudiated the claim by letter dated 17/03/2005 stating that the disease was pre-existing. Aggrieved thereby, complainant approached the forum.
Appellant filed written response justifying repudiation of the claim on the ground that the disease for which complainant had undergone treatment was a pre-existing disease, since the complainant had stated before the Medical officer in the hospital that he was suffering from chest pain for about two months before 12/07/2004 which would then date back to May 2014 before the date of taking of policy i.e.03/06/2004.
Forum considered the rival contentions and then came to pass impugned order. Aggrieved thereby, Insurance Company has preferred this appeal.
We heard the learned counsel Mr.Amol More proxy for Mr.Sanjay Mhatre-Advocate for the appellant and learned counsel Mr.T.S.Vidwans for the respondent.
Learned counsel for the appellant principally relies on the observations in the discharge summary given by Grant Medical Foundation Ruby Hall Clinic, where the complainant has stated to have given clinical history of radiating chest pain on the left hand side since 1/2 months. We take it that this figure is not half month but one or two months. Learned counsel for the appellant also relies on opinion of one Dr.Anil Ronghe, which was supported by an affidavit.
Dr.Anil Ronghe seems to be a Medical Insurance Consultant. He concluded only on the basis of clinical history recorded in the discharge summary that since history of chest pain was for one or two months as per the discharge summary, claimed condition falls under pre-existence and non disclosure. We are unable to see as to how merely because the complainant had some chest pain, he should dream that he has some serious ailment which would require angioplasty when he took the insurance cover. Chest pain could be for the variety of reasons and, therefore, merely on the basis of complainant stating about chest pain while giving his history, it cannot be inferred that he knew that he was suffering from some heart ailment and that he suppressed this information from the Insurance Company. Learned counsel for the appellant could not show us any column in the proposal form, which is unfortunately not on record, to show that the complainant was also required to disclose any pain that he suffered from to enable the Insurance Company to refuse to insure him. In view of this, we see no fault in the order passed by the District Forum and dismiss the appeal.
Pronounced on 4th December, 2013.
[HON'ABLE MR.
JUSTICE R.C.Chavan] PRESIDENT [HON'ABLE MR.
Dhanraj Khamatkar] Member Ms.