State Consumer Disputes Redressal Commission
Avinash Sood Son Of Shri B.D. Sood, ... vs 1.United India Insurance Co. Ltd., ... on 22 October, 2012
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, HARYANA, PANCHKULA First Appeal No.1269 of 2010 Date of Institution: 03.09.2010 Date of Decision: 22.10.2012 Avinash Sood son of Shri B.D. Sood, resident of House No.3703, Braham Niwas, Subhash Park Marg, Ambala Cantt (Haryana). Appellant (Complainant) Versus 1. United India Insurance Co. Ltd., Divisional Office, First Floor, Possenette Bhawan, Tilak Road, Hyderabad-500001, through the Branch Manager, LIC Building, Ambala Cantt. 2. Family Health Plan Ltd. Aditya JR Tower, 8-2-120/86/9/1 and B, 3rd Floor, Road No.2, Banjara Hills, Hyderabad-500034. 3. Adhra Bank, through its Branch Manager, Ambala Cantt. Respondents (Ops) BEFORE: Honble Mr. Justice R.S. Madan, President. Mr. B.M. Bedi, Judicial Member. For the Parties: Shri Piyus Mittal, Advocate for appellant. Shri D.K. Dogra, Advocate for respondents. O R D E R
Justice R.S. Madan, President:
This appeal has been preferred against the order dated 30.07.2010 passed by District Consumer Forum, Ambala whereby complaint filed by complainant (appellant herein) was dismissed.
The brief facts of the present case as emerged from the record are that that the complainant had purchased medi-claim Insurance Policy from the opposite parties for the period 11.6.2005 to 10.6.2006. The policy was further renewed for the period 11.6.2006 to 10.6.2007. The complainant was admitted in Forties Hospital, Sector 62, Phase8, Mohali for treatment on 12.9.2006 and was discharged on 14.9.2006. In the above said hospital Coronary angiographies of the complainant was done which revealed left renal artery stenosis and was diagnosed as renovescular hypertension. The complainant was taken up for CABG in March, 2006. After that, the complainant was admitted in Forties Hospital, Mohali for treatment for PTRA with stent to left renal artery was undertaken on 12.09.2006 and was discharged on 14.09.2006. After getting the treatment, the hospital demanded a sum of Rs.1,21,699.22 for treating the complainant upon which the complainant told that he was entitled for free treatment.
But under the compelling circumstances, the complainant deposited the aforesaid amount with the hospital and thereafter claimed from the opposite party No.2 but complainants claim was denied on the ground that the complainant had taken the treatment for pre-existing disease. Challenging the repudiation of his claim, the complainant filed complaint before the District Forum.
Upon notice, the opposite parties No.1 and 3 appeared and contested the complaint. Opposite Party No.2 did not contest the complaint and was proceeded exparte.
Opposite Party No.1 in its written statement stated that the complainant had previously been hospitalized at M/s Delhi Heart and Lungs Institute on 6.3.2006 and the Medical Team of T.P.A. had opined that the triple vessel coronary artery disease associated with left renal artery stenosis (80%) is a pre-existing disease. The opposite party No.2 had scrutinized the documents received from the hospital and did not accord permission for cashless facility in view of the problem being a pre-existing one. But this fact was not disclosed by the complainant at the time of obtaining the Insurance Policy and had given false answers in the proposal form. It was prayed that the complaint merited dismissal.
Both the parties adduced evidence in support of their respective claims. On appraisal of the pleadings of the parties and the evidence adduced on the record, District Consumer Forum finding no substance in complainants version dismissed the complaint.
Aggrieved against the order of the District Consumer Forum, the complainant has come up in appeal.
Arguments heard. File perused.
At the very outset the question for consideration before us is whether the disease for which the complainant had taken treatment from Forties Hospital, Mohali, was a pre-existing disease?
Admittedly the first medi-claim Insurance Policy was taken by the complainant for the period 11.6.2005 to 10.6.2006. Annexure C-6 is the certified issued from Fortis Hospital, Mohali which reflects that the complainant Avinash Sood was an old patient for coronary angiography in March, 2006. Meaning thereby the complainant played fraud with the opposite party at the time of obtaining the Insurance Policy because the complainant had not disclosed the pre-existing ailment in the proposal form. Thus, the claim of the complainant falls under Exclusion Clause the relevant part of which is reproduced herein below:-
4. EXCLUSIONS 4.0 The company shall not be liable to make any payment under this policy in respect on any expenses whatsoever incurred by any insured Person in connection with or in respect of:
4.1 All diseases/injuries which are pre-existing when the cover incepts for the first time 4.2 x x x x x x 4.3 x x x x x x The perusal of the above mentioned exclusion clause 4.1 clearly shows that the claim of the complainant is not payable and therefore no deficiency in service can be attributed to the opposite parties in repudiating complainants claim. No case for interference in the impugned order is made out whereby the complaint was dismissed.
Hence, finding no merit in this appeal, it is dismissed.
Announced: Justice R.S. Madan 22.10.2012 President B.M. Bedi Judicial Member