DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

WEST TRIPURA :  AGARTALA

 

 

CASE   NO:   CC- 06  of  2023

 

Smt. Rina Das,

W/O- Sri Bhulendra Roy,

L.N. Bari Road, Banamalipur,

Agartala, Pin- 799001, 

District- West Tripura. ...........Complainant.

 

-VERSUS-

 

 

 

    __________PRESENT__________

 

  SRI GOUTAM DEBNATH

  DISTRICT CONSUMER  

DISPUTES REDRESSAL COMMISSION,

      WEST TRIPURA, AGARTALA. 

 

 

DR (SMT)  BINDU  PAL

MEMBER, 

DISTRICT CONSUMER 

DISPUTES REDRESSAL COMMISSION, 

WEST TRIPURA, AGARTALA

 

 

SRI SAMIR GUPTA

MEMBER,

  DISTRICT CONSUMER 

 DISPUTES  REDRESSAL COMMISSION,

WEST TRIPURA,  AGARTALA. 

 

 

 

C O U N S E L

 

For the O.P.     :  Sri Rajib Saha,

 

 

F I N A L    O R D E R

1. This case is filed by Smt. Rina Das of Banamalipur, Agartala, West Tripura(here-in-after called “the complainant”) against the O.P. namely the Branch Manager, Cholamandalam MS General Insurance Company Ltd., Agartala Branch, RMS Chowmuhani, Agartala, West Tripura(here-in-after called as “the O.P.”) alleging deficiency in service on the part of the O.P. 

1.1 The case in short is that the complainant Smt. Rina Das purchased a policy of Health Insurance from the O.P. for the period from 25.06.2020 to 24.06.2021. Complainant was admitted in ILS Hospital during the subsistence of the policy and the O.P. paid the hospital bill raised by the complainant.

1.2 The complainant contacted the Sales Executive of the O.P. Insurance company and purchased a new policy for Rs.10 lakhs from the Bank of Boroda, the Corporate Agent of the O.P. Insurance company. This policy was valid from 18.06.2022 to 17.06.2023. 

1.3 On 03.09.2022 the complainant was admitted in ILS Hospital, Agartala and was discharged on 07.09.2022. A cashless claim was raised but denied by the O.P. As such the complainant got discharged from the ILS Hospital on payment of hospital bill and thereafter raised reimbursement claim with the O.P. which was repudiated by the O.P. on the ground that the complainant has been suffering from diabetes and hypertension since 30 years. As such for non disclosure of material information the claim was repudiated. 

 

2. The O.P. Insurance Company submitted written objection stating inter alia that the Sales Executive of the O.P. Insurance company and Bank of Baroda, the Corporate Agent of the O.P. Insurance have not been impleaded as party. It is further pleaded that the claim was repudiated for non disclosure of previous fact of diabetes and Hypertension since last 30 years. 

3. The parties submitted evidence and documents.

4. Hearing argument the following points are taken up for discussion and decision:-

 

  Decision  & Reasons for decision:- 

5. Both the points are taken up together.

5.1 Proceeding before the Consumer Commission is summary procedure. Therefore, the nicety of Civil Procedure Code is not applicable except the principle only. The fact of dispute is whether the complainant suppressed material fact of illness at the time of obtaining the policy of Insurance. Therefore, non impleadment of the Corporate Agent i.e., the Bank of Baroda or the Sales Executive of O.P. Insurance company is not a material issue. 

5.2 Admittedly, the complainant was earlier admitted in ILS Hospital with complaint of diabetes and hypertension crisis during the subsistence of earlier policy for the period from 25.06.2020 to 24.06.2021. That claim of the complainant was paid by the O.P. Insurance company. The present illness of the complainant is also hypertension crisis with acute hyperglycemia state and mild anaemia as we find from the discharge summary of ILS Hospital dated 07.09.2022. Therefore, the complainant did not suffer from a new disease which was not known by the O.P. Insurance company at the time of issuing the 2nd policy of Insurance for the period from 18.06.2022 to 17.06.2023. 

5.3 Further, we do not find any paper issued by any authority that the complainant has been suffering from such disease for last 30 years as pleaded by the O.P. Insurance company. Therefore, we find no reason to accept the plea of the O.P. Insurance company and this is itself deficiency in service on the part of the O.P. Insurance company.

6. Both the points are decided accordingly.

7. In the result, the O.P. is directed to pay Rs.1,12,950/- i.e., the cost of her treatment in the hospital with a further sum of Rs.10,000/- as litigation cost. The O.P. Insurance company has to pay this amount within 30 days from today, otherwise it shall carry interest @ 7.5% P.A. from today till the date of actual payment. 

8. The case stands disposed of. Supply copy of this Final Order free of cost to both the parties.   

   

Announced.

 

 

 

SRI  GOUTAM DEBNATH

PRESIDENT,

DISTRICT CONSUMER  DISPUTES 

REDRESSAL COMMISSION,

WEST TRIPURA,  AGARTALA

 

 

 

 

 

DR (SMT)  BINDU  PAL

MEMBER, 

DISTRICT CONSUMER DISPUTES 

REDRESSAL COMMISSION, 

WEST TRIPURA, AGARTALA

 

 

SRI SAMIR  GUPTA

MEMBER, 

DISTRICT CONSUMER DISPUTES  

REDRESSAL COMMISSION,

WEST TRIPURA, AGARTALA.