LAKHWINDER SINGH Vs. UNITED INDIA INSURANCE COMPANY LIMITED

JUDGEMENT

(1.) THIS is an appeal filed by the complainant against order dated 16.12.2008 passed by District Consumer Disputes Redressal Forum -I, UT, Chandigarh (for short hereinafter to be referred as District Forum) passed in complaint case No. 852 of 2008.

(2.) BRIEFLY stated the facts of the case are that the complainant No. 1 (Lakhwinder Singh) working as Deputy Manager of OP No. 3 (HFCL Infotel Limited) who secured a Group Medi -claim Insurance Policy from OPs No. 1 and 2 (United India Insurance Company Limited) under which its employees and their dependents were covered for various medical expenses incurred by them on their treatment. The complainant No. 2 i.e. Gurbachan Kaur is the mother of complainant No. 1 Lakhwinder Singh and she is dependent upon her son Lakhwinder Singh. The complainant No. 2 being a patient of hypertension felt chest pain on 10.1.2006 and was immediately taken to Government Medical College and Hospital, Sector -32, Chandigarh from where she was referred to P.G.I, Chandigarh. On 11.1.2006 complainant No. 2 was admitted in the PGI, Chandigarh where the complainant No. 1 incurred total expenses of Rs. 1,20,525 on her treatment and in the month of February, 2006 the original bills were submitted to OP No. 3 for claim. The correspondence was started between the OP No. 3 and OP No. 1 through letter Annexure C -12 stated their inability to accept the liability. Thereafter the complainant No. 1 made a representation to OP No. 3 for illegal and wrongful rejection of the claim. OP No. 3 wrote a letter to OP No. 1 for reconsideration of the claim but the OP No. 1 vide their letter Annexure C -14 finally stated that in view of facts explained in Annexure C -12 they were unable to reconsider the claim. The abovesaid act of OP amounts to deficiency in service. Hence, the complaint was filed.

(3.) REPLY was filed by OPs No. 1 and 2 and they pleaded that the complainant No. 2 was a hypertension patient for the last six years and having chest pain for the last 4 -5 years. Dr. N.P. Singh, medical expert gave the opinion that as per the medical record, the complainant No. 2 was having stable angina for the last 4 -5 years and which was confirmed in Angiography. It was pleaded that vide letter dated 11.4.2006, OP No. 3 was informed by the answering OPs that due to pre -existing disease, the claim of the complainant was repudiated. It was further pleaded by the answering OPs that as per clause 4.1 of the terms and conditions of the policy, the answering OPs would not be liable to make any payment in connection with or in respect of such diseases which have been in existence at the time of proposing this insurance. Hence, it was pleaded by the answering OPs that there was no deficiency in service on their part and prayed for dismissal of the complaint.