State Consumer Disputes Redressal Commission
1. The Oriental Insurance Co. Ltd. ... vs Jai Parkash Son Of Shri Radhey Shyam, ... on 11 October, 2012
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, HARYANA, PANCHKULA First Appeal No.515 of 2010 Date of Institution: 15.04.2010 Date of Decision: 11.10.2012 1. The Oriental Insurance Co. Ltd. Branch Office, CBO-8, Kashmiri Gate, 1576 Church Road, Kashmiri Gate, Delhi-6 and Branch Office at 204-R, Model Town, Atlas Road, Sonepat, through Shri B.S. Negi, Regional Manager, Regional Office, LIC Building, II Floor, Jagadhri Road, Ambala Cantt. 2. M/s Vipul Medical Corp. Private Limited 515 Udyog Vihar Phase V Gurgaon. Appellants (Ops) Versus Jai Parkash son of Shri Radhey Shyam, Resident of H.No.110/5, Near Gaosala, Jatwara, Sonepat. Respondent (Complainant) BEFORE: Honble Mr. Justice R.S. Madan, President. Mr. B.M. Bedi, Judicial Member. For the Parties: Shri D.C. Kumar, Advocate for appellants. Respondent exparte. O R D E R
Justice R.S. Madan, President:
This appeal has been preferred against the order dated 23.02,.2010 passed by District Consumer Forum, Sonepat whereby complaint filed by complainant (respondent herein) against the appellants-opposite parties seeking insurable benefits in respect of medi-claim policy was accepted and following direction was issued:-
.it is directed that the respondent No.1 shall pay a sum of Rs.2,97,571/- to the complainant with interest @ 9% p.a. (on account of his treatment for the period from 28.7.2007 to 15.7.2009) from 28.7.2007 till realization of final payment. The respondent No.1 is also directed to pay a sum of Rs.20,000/- as compensation on account of mental agony, harassment and litigation expenses.
The order be complied within one month. Accordingly, the present complaint stand disposed of.
Undisputed facts of the present case are that complainant had been taking the mediclaim policies for himself and his family from the appellants-opposite parties. The first policy was taken for the period 13.01.2006 to 12.01.2007,second policy was for the period 13.01.2007 to 12.01.2008 and further the policy was taken from 13.01.2008 to 12.01.2009. The opposite party No.1 at its own had appointed the opposite party No.2 as third party Administrator who had issued the Cash less treatment card to the complainant. Complainant suffered stomach pain, vomiting, high BP, uneasiness, swelling of foot and difficulty in passing the urine. He was taken to Civil Hospital, Sonepat on 22.03.2007 from where he was referred to AIIMS, New Delhi. When the condition of complainant deteriorated, he was taken to Mata Chanan Devi Hospital, New Delhi on 28.03.2007 where he remained in emergency ward and kept in ICU and was discharged on 30.03.2007. According to the complainant, he paid Rs.14,395/- in the said hospital for treatment and medicine etc. The complainant was diagnosed Acute on CKD renal failure, ACC, HTN. Information was given to the opposite parties but to no effect. The complainant paid the aforesaid payment to the hospital. Thereafter, as per the advice of the doctors, the complainant was put on Haemo dialysis which was got done in the same hospital on 31.03.2007. According to the complainant, he spent Rs.1,44,000/- on dialysis. Complainant filed complaint No.272/2007 before the District Forum, Sonepat wherein vide order dated 27.11.2008, a sum of Rs.1,68,293/- was awarded to the complainant including interest etc. After the decision dated 27.11.2008, the complainant submitted his claim for Rs.1,97,687/- on 9.4.2009 for the treatment from 28.7.2007 to 14.3.2009 the bills of which were sent to the opposite party No.2 but despite that the expenses incurred by the complainant were not paid to him. Forced by these circumstances, the complainant filed complaint.
Upon notice, the opposite parties appeared and contested the complaint. Opposite Party No.2 failed to appear and was proceeded exparte. Opposite party No.1 in its written statement took the plea that the opposite party No.2 had received the claim papers of the complainant on 10.04.2009 for the treatment pertaining to the period 28.7.2007 to 12.01.2009 but as per condition No.5.4 of the mediclaim insurance policy, immediate information was to be given to the opposite parties within 48 hours of admission before discharge from the hospital or nursing home unless waived in writing. It was further stated that the complainant was suffering from chronic disease for the last several years and the problem which had occurred on 22.3.2007, was the result of old chronic disease from which the complainant was suffering. Thus, denying any kind of deficiency in service, the opposite party No.1 prayed for dismissal of the complaint.
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 accepted complaint and issued direction to the opposite party No.1 as noticed in the opening para of this order.
Aggrieved against the order of the District Consumer Forum, the opposite parties have come up in appeal.
Heard.
The purchase of the medi-claim insurance policy by the complainant is not disputed between the parties. It is also not disputed that the complainant had taken treatment during the subsistence of the Insurance Policy. The opposite party-Insurance Company is denying the claim of the complainant on the ground that the complainant was suffering from chronic disease i.e. acute of CKD renal failure, ACC HTN from long prior to taking of the first policy.
There is nothing on the record to suggest that the complainant had suppressed the material information before taking of the Insurance Policy. No cogent and convincing evidence has been produced by the opposite parties that the disease for which treatment was taken by the complainant and claim was submitted with the opposite parties, was a pre-existing disease. Mere assumption and presumption without any cogent and convincing evidence cannot take the shape of proof.
Having considered the facts and circumstances of the case, we do not find any infirmity in the impugned order. No case for interference in the impugned order is made out.
Hence, this appeal is dismissed being devoid of any merit.
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 and revision, if any filed in this case.
Announced: Justice R.S. Madan 11.10.2012 President B.M. Bedi Judicial Member