Decided on January 02,2020

Sumit J. Ramchandani Respondents


PREM NARAIN,J. - (1.) This appeal has been filed against the judgment dated 13.10.2014 of the Maharashtra State Consumer Disputes Redressal Commission Mumbai in Complaint no.CC/09/2.
(2.) The brief facts of the case are that the father of the respondent/ complainant took four personal accident insurance policies from the appellant/ opposite party - Royal Sundram Alliance Co. Ltd., with the following details: S no. Policy no. and Period Sum assured 1. PE00085132000100-E049 dated 04.04.2007 to 03.03.2009 Rs,4,00,000/- 2. PE0084733000100 dated 22.03.2007 to 21.03.2009 Rs.4,00,000/- 3. PASBIG0008 dated 02.01.2007 to 01.01.2008 Rs.10,00,000/- 4. PE00084865000100-E049 dated 26.03.2007 to 25.03.2009 Rs.4,00,000/-
(3.) During the currency of these policies the life assured visited Kailash Mansarovar along with his family. It is the case of the complainant that when the insured was climbing the "icy kailash paravat"?, he fell down on 05.09.2007 and sustained injury. The insured was brought to Mumbai on 06.09.2007 and was admitted in Nanavati Hospital, Mumbai where his one leg was amputated due to gangrene. After being discharged from the Nanavati Hospital on 02.10.2007 he was again admitted to Hinduja Hospital on 15.10.2007 and he was discharged from the Hinduja Hospital on 22.10.2007. Due to loss of blood, he became very weak and ultimately the insured died on 03.12.2007. The insurance claim was submitted by the complainant to the insurance company after the amputation of one leg and the claim under the policies was repudiated vide letter dated 09.01.2008 which reads as under: "We refer to a letter dated 22.10.2007 with regard to the claim preferred over the policies taken for Mr Harish Ramchandani. On scrutiny of the hospital records, it is noted that the insured developed Gangrene due to exposure to the cold temperature, this is also confirmed by our service provider in his report on Hospital Cash claim lodged for the same incident. We reproduce the policy conditions: The company shall not be liable for payment of compensation in respect of death, injury or disablement of the insured person as a result of, or which is contributed to by, the insured person suffering from any pre-existing condition or pre-existing physical or mental defect or infirmity. Pre-existing condition shall mean any ailment which existed prior to the effective date of this insurance. There is no evidence of accidental injury mentioned in the hospital record, further, the disablement is not due to accident but it is due to the pre-existing diabetes. In view of the above, we are unable to consider your claim and we sincerely regret our inability to assist you on this occasion."? ;

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