STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED Vs. JASPAL SINGH SONI
LAWS(UTRCDRC)-2014-3-1
UNION TERRITORY STATE CONSUMER DISPUTE REDRESSAL COMMISSION
Decided on March 05,2014

STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED Appellant
VERSUS
Jaspal Singh Soni Respondents

JUDGEMENT

- (1.)THIS appeal is directed against the order dated 27.11.2013, rendered by the District Consumer Disputes Redressal Forum -II, UT, Chandigarh (hereinafter to be called as the District Forum only) vide which it allowed the complaint filed by the complainant and directed the Opposite Party (now respondent) as under: -
"i) To pay an amount of Rs.19,287/ - to the complainant towards reimbursement of medical claim of his son.

ii) To pay Rs.7,000/ - as compensation for mental agony and harassment;

iii) To pay Rs.5,000/ - as costs of litigation.

9. This order be complied with by the opposite party, within 45 days from the date of receipt of its certified copy, failing which the amounts at Sr.No.(i) and (ii) above shall carry interest @18% per annum from the date of filing of this complaint till actual payment besides payment of litigation costs".

(2.)IN brief, the facts of the case, are that the complainant purchased a medi -claim policy (C -1) for himself and his family members, by paying premium of Rs.13,753/ -. The said policy was having the sum insured of Rs.3.00 lacs and it was valid from 24.7.2012 to 23.7.2013. It was stated that the terms and conditions of the policy were never supplied by the opposite party. It was further stated that on 11.3.2013, the son of the complainant namely, son Master Poojan Soni, fell down and became unconscious. He was shifted to Fortis Hospital on 11.3.2013 and was discharged on 12.3.2013. The complainant spent an amount of Rs.31,000/ - on his treatment, but could preserve bills of Rs.19,287/ - only. It was further stated that the complainant submitted his claim alongwith all the documents but the opposite party, vide its letter dated 22.4.2013 illegally repudiated the claim, on the ground of pre -existing disease, and mis -representation/non -disclosure of material facts. It was further stated that the Opposite Party, was deficient, in rendering service, as also indulged into unfair trade practice. When the grievance of the complainant was not redressed, left with no alternative, a complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter to be called as the "Act" only), was filed.
(3.)IN its written reply, the Opposite Party did not dispute the facts, with regard to the purchase of the Policy by the complainant, admission of his son in Fortis Hospital and the filing of claim. However, it was stated that, upon perusal of the record, it transpired that the complainant was suffering from a pre -existing disease as he had undergone bilateral frontal craniotomy with ACF (Anterior Cranial Fossa) repair in January 2012. It was further stated that while taking the Policy, in question, the complainant had concealed the aforesaid fact and, therefore, the claim was rightly repudiated. It was denied that, the Opposite Party was deficient, in rendering service. The remaining allegations were denied, being false.
The Parties led evidence, in support of their case.



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