State Consumer Disputes Redressal Commission
Reliance Gen.Insurance Co. vs Yogesh Modi on 5 September, 2017
Daily Order STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA First Appeal No : 672 of 2016 Date of Institution: 21.07.2016 Date of Decision : 05.09.2016 1. The General Manager, Reliance General Insurance Company Limited, Office at Delhi-Hisar Road, Hisar. 2. Reliance General Insurance Company Limited, 570, Naigaon, Cross Road, Next To Royal Industrial Estate, Wadala (West Mumbai)-400031 through its Authorized Signatory. (Both the appellants through its Regional Office and Authorized Signatory Sh. Amit Chawla, Manager, Legal, Regional Office, SCO 145-146, 2nd Floor, Sector 9-C, Madhya Marg, Chandigarh). Appellants-Opposite Parties No.1 & 2 Versus 1. Yogesh Modi son of Sh. Nem Chand Modi, resident of Bhadra Bazar, Karnanian Street, Sirsa. Respondent-Complainant 2. Dipesh Jain son of Sh. Mohan Lal Jain, Agent of Reliance General Insurance Company Limited, Office at Delhi Hisar Road at Hisar, resident of Near Parshu Ram Chowk, Subhash Basti Begu Road, Sirsa. Respondent-Opposite Party No.3 CORAM: Hon'ble Mr. Justice Nawab Singh, President. Shri Balbir Singh, Judicial Member.
Present: Shri Satpal Dhamija, Advocate for appellants. Shri Tarun Gupta, Advocate for the complainant
(Service of respondent No.2-Dipesh jain dispensed with vide order dated October 18th, 2016) O R D E R NAWAB SINGH J.(ORAL) This Opposite Parties'- Reliance General Insurance Company Limited (for short 'the Insurance Company') appeal is directed against the order dated May 25th, 2016 passed by District Consumer Disputes Redressal Forum, Sirsa (for short 'the District Forum') whereby complaint filed by Yogesh Modi-complainant was allowed. The Insurance Company was directed to pay Rs.1,44,738/- alongwith interest at the rate of 9% per annum from the date of filing of the complaint, that is, February 07th, 2011 till realization; Rs.10,000/- as compensation and Rs.2200/- litigation expenses to the complainant on account of medical expenses incurred by him on the treatment of his daughter Vanya Modi.
2. The complainant purchased Reliance Healthwise Policy (Annexure A-1) from the Insurance Company for the period September 29th, 2009 to September 28th, 2010. The policy tenure was one year. The complainant, his wife Varsa, his daughters Yashasvi Modi and Vanya Modi were insured under the said policy. Vanya Modi fell ill and took treatment of Congenital Heart Defect from Fortis Escort Heart Institute, New Delhi. The complainant spent Rs.1,44,738/- on the treatment. He filed claim with the Insurance Company but it was not settled on the ground that the claim of complainant falls under the Exclusion Clause. Vanya Modi suffered heart disease, which was a Congenital Internal Disease occurred during the first year of the operation of the insurance policy.
3. As per Policy Exclusions, the Insurance Company was not liable to make any payment for any claim directly or indirectly caused by, based on, arising out of or howsoever attributable to any of the following:-
"3. Expenses incurred on treatment of following diseases, illness, injury within the first year from the inception of this Policy:
Cataract Benign Prostatic Hypertrophy Myomectomy, Hysterectomy or menorrhagia or fibromyoma unless because of malignancy Dilation and curettage Hernia, Hydrocele, congenital internal disease, fistula in anus, sinusitis Skin and all internal tumors/cysts/nodules/polyps of any kind including breast lumps unless malignant/adenoids and hemorrhoids Dialysis required for chronic renal failure Gastric and Duodenal ulcers
4. It is not in dispute that daughter of complainant suffered congenital heart defect during the first year of the operation of the insurance policy. Thus, the disease of the complainant fell under aforesaid exclusion clause of the insurance policy. The Insurance Company was not liable to make the payment of expenses incurred by the complainant on the treatment of his daughter. Thus, the District Forum fell in error in allowing the complaint and the impugned order cannot sustain.
5. For the reasons recorded supra, the appeal is accepted, the impugned order is set aside and the complaint is dismissed.
6. The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the appellants against proper receipt and identification in accordance with rules, after the expiry of period of appeal/revision, if any.
Announced 05.09.2017 (Balbir Singh) Judicial Member (Nawab Singh) President UK