State Consumer Disputes Redressal Commission
The New India Assu. Co. Ltd. vs Vijay Ku. Shukla And Other'S on 30 June, 2022
Daily Order M. P. STATE CONSUMER DISPUTES REDRESSAL COMMISSION, BHOPAL PLOT NO.76, ARERA HILLS, BHOPAL FIRST APPEAL NO. 668 OF 2009 (Arising out of order dated 28.02.2009 passed in C.C.No.333/2006 by the District Commission, Jabalpur) THE NEW INDIA ASSURANCE CO.LTD. PARYAWAS BHAWAN, ARERA HILLS, BHOPAL (M.P.) ... APPELLANT. Versus 1. VIJAY KUMAR SHUKLA, S/O SHRI P.N. SHUKLA, R/O B-1 MAIHAR HOUSE, PACHPEDI, JABALPUR (M.P.) 2. SMT. CHANDRIKA SHUKLA, W/O VIJAY KUMAR SHUKLA, S/O SHRI P.N. SHUKLA, R/O B-1 MAIHAR HOUSE, PACHPEDI, JABALPUR (M.P.) 3. M/S FAMILY HEALTH PLAN LTD 102 CLASSIC DIAMOND, 72 B SCHEME NO.84, ADJACENT BOMBAY HOSPITAL, INDORE (M.P.) ... RESPONDENTS. BEFORE: HON'BLE DR. (MRS) MONIKA MALIK : PRESIDING MEMBER HON'BLE DR. SRIKANT PANDEY : MEMBER HON'BLE SHRI D. K. SHRIVASTAVA : MEMBER COUNSEL FOR PARTIES : Ms. Preetima Shrivastava, learned counsel for the appellant. Shri Amarpal Singh, learned counsel for the respondent no.1 & 2. None for the respondent no. 3. O R D E R
(Passed On 30.06.2022) The following order of the Commission was delivered by Dr. Monika Malik, Presiding Member.
This appeal by the opposite party /appellant is directed against the order dated 28.02.2009 passed by the District Consumer Disputes Redressal Commission, Jabalpur (For short 'District Commission') in -2- C.C.No.333/2006 whereby the District Commission has partly allowed the complaint filed by the complainants.
2. The complainants/respondent no.1 and 2 had filed a complaint before the District Commission stating that they had obtained a mediclaim policy on 28.02.2000 from the opposite party no.1/appellant, bearing policy no. 450500/48/05/20/70050105 w.e.f. 01.03.2006 to 28.02.2007. The aforesaid policy is continuously being renewed till 2006. The complainant no.2 (hereinafter referred to as 'insured') felt pain in her abdomen and was admitted in Sir Gangaram Hospital, New Delhi, where she treated for hernia and incurred total expenditure of Rs.1,23,997.75. The claim was filed with the opposite party/appellant insurance company, which was denied and therefore alleging deficiency in service on part of the opposite party-insurance company, the complainants approached the District Commission, seeking claim amount with compensation and costs.
3. The opposite party no.1 insurance company resisted the complaint on the ground that the complainant no.2 was having hernia before obtaining the policy cover. The present ailment is due to earlier surgeries underwent in the year 1990 & 1991. The insured had also not lodged any claim regarding surgery for hernia done earlier in the year 2004. Since there was material suppression on part of the insured in the proposal form -3- regarding her condition, her claim is not payable as per clause 4.1 of the policy terms and conditions.
4. The District Commission partly allowed the complaint filed by the complainants, and directed the opposite parties to pay Rs.1,23,997.75/- towards expenses occurred in the treatment to the complainants with Rs.1,000/- towards compensation and Rs.1,000/- as costs. Hence this appeal.
5. Heard. Perused the record.
6. On careful perusal of evidence available in the record of the District Commission we find that 'Annexure D-2' which is 'discharge summary' of Sir Gangaram Hospital, New Delhi, where the complainant no.2 was treated for incisional hernia. In the history column, there is mention of H/O Hyperthyroidism since 1990, H/O LSCS (Lower Segment Caesarian Section) twice in 1990 & 1991. Importantly there is no mention of history of hernia or treatment taken in aforesaid regard, before inception of policy cover. It has rightly been held by the District Commission that certainly there is history of 'open incisional hernia repair' in December-2004 but an adverse inference cannot be drawn, when the complainants did not opt for claim regarding the said operation.
7. Merely, because the insured underwent caesarian section in the year 1990-91, it cannot be conclusively held that she developed hernia due -4- to said operation only and was aware of this occurrence. Hernia may occur due to caesarian section but it is not the only cause for hernia. It is not established that it was in the knowledge of the insured that she was suffering from hernia, at the time of obtaining policy cover. There is no reason that a person would wait for 4 years, before getting it operated. It is also an admitted fact that the policy obtained in the year 2000 is continuous uptill 2006. The complainants deserve the claim amount, which has rightly been awarded by the District Commission.
8. Therefore, to conclude, rejection of the complainant's claim by the appellant-insurance company, citing clause 4.1 of the policy terms and conditions is unjustified and unsustainable.
9. In view of the above finding, no illegality or irregularity in the impugned order, we affirm the same.
10. As a result, this appeal, which is devoid of any merit is dismissed with no order as to costs.
(Dr. Monika Malik) (Dr.Srikant Pandey) (D. K. Shrivastava) Presiding Member Member Member